Columbia  Winibtv&itp 

in  ti)C  Citj»  of  J^eSm  ^orb 

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I^eference  Mirarp 


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http://www.archive.org/details/localanesthesiai1912fisc 


Man  forever  will  err;  yet  an  innate  longing  desire 
Draws  the  aspiring  mind  gently  toward  the  truth. 

Goethe. 


LOCAL    ANESTHESIA 

IN 

DENTISTRY 


WITH  SPECIAL  REFERENCE  TO  THE  AIUCOUS 
AND  CONDUCTIVE  METHODS 

A  CONCISE  GUIDE   FOR   DENTISTS,  SURGEONS  AND  STUDENTS 

BY 

PROFESSOR    DR.   GUIDO    FISCHER 

DIRECTOR  OF   THE   ROYAL  DENTAL  INSTITUTE  OF  THE   UNIVERSITY  OF  MARBURG 

TRANSLATED    FROM    THE   SECOND  GERMAN    EDITION 
BY 

RICHARD  H.  RIETHMLTLLER,  Ph.D.  (Univ.  of  Pa.) 

DENTAL  DEPARTMENT  OF  THE  MEDICO-CHIRURGICAL  COLLEGE,   PHILADELPHIA 

ILLUSTRATED  WITH    105    ENGRAVINGS,  MOSTLY    COLORED 


LEA    &    FEBIGER 

P.HILADELPHIA    AND    NEW    YORK 
1912 


Entered  according  to  the  Act  of  Congress,  in  the  year  1912,  by 

LEA   &   FEBIGER 
in  the  office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE 


While  efforts  toward  the  abolition  or  reduction  of  pain  are  in- 
separably interwoven  with  the  history  of  the  human  race,  it  was 
not  until  the  introduction  of  general  anesthesia  with  nitrous  oxid 
by  Wells  in  1844,  with  ether  by  Morton  in  1846,  and  with  chloroform 
by  Simpson  in  1847,  that  "the  beautiful  dream  of  the  elimination  of 
pain  became  a  reality,"  to  use  Dieffenbach's  words.  Local  anesthesia, 
although  prior  to  1884  it  had  been  induced  by  freezing,  as  by  salt  and 
ice,  ether,  and  ethyl  chlorid,  did  not  attain  general  popularity  before 
that  year,  when  Roller  demonstrated  the  anesthetic  properties  of 
cocain.  Since  then  the  advance  of  surgical  anesthesia,  both  general 
and  local,  toward  perfection  has  reached  a  remarkable  point  of  devel- 
opment, for  the  attainment  of  which  humanity  owes  to  dentistry  no 
less  a  debt  of  gratitude  than  it  does  to  medicine. 

In  operative  interventions  in  the  oral  cavity,  which,  while  in^•olving 
but  a  limited  area,  are  so  extremely  painful,  local  anesthesia  seemed 
from  the  beginning  to  be  specially  indicated;  in  fact,  so  welcome  has 
been  the  elimination  of  pain  in  dentistry  that  the  limits  necessarily 
attaching  to  this  beneficent  aim  have  at  times  been  overstepped,  and 
progress  has  been  jeoparded,  and  legitimate  and  conscientious  effort 
discredited  by  the  exploits  in  "painless  dentistry-"  of  unethical  practi- 
tioners. The  ethical  dentist  should,  therefore,  gladly  avail  himself 
of  a  guide  which,  issuing  from  the  pen  of  a  recognized  authority,  will 
aid  him  in  adopting  a  safe  and  scientific  method  of  inducing  local 
anesthesia,  in  raising  the  standard  of  his  operative  work,  in  sparing- 
pain  to  his  patients,  and  conserving  his  own  nervous  energy.  The 
demands  that  modern  civilization  is  making  upon  our  \ital  forces 
are  so  great  that  anesthesia  is  imperatively  demanded  CAcn  in  minor 


VI  PREFACE 

dental  operations,  and  the  daily  and  urgent  pleas  for  humane  dentistry 
should  no  longer  be  left  unheeded  even  by  the  most  conservative 
practitioner. 

The  timeliness  of  this  guide  is  fully  evinced  by  the  fact  that  the 
first  German  edition  was  exhausted  within  ten  weeks,  and  that  Ch. 
J.  Fleischmann  has  based  his  monograph  on  "Local  Anesthesia  in 
Operative  Dentistry, "  which  has  since  appeared  in  French,  on  Fischer's 
investigations.  The  author  is  convinced  that  local  anesthesia,  in 
its  present  perfection,  is  destined  to  supplant  general  anesthesia  in 
dentistry  almost  entirely.  He  has,  therefore,  laid  chief  stress  upon 
an  exact  presentation  of  the  technique  of  injection,  and  by  painstaking 
studies  of  the  anatomy,  physiology,  and  pharmacology  involved  has 
succeeded  in  surmounting  successfully  the  defects  that,  until  recently, 
still  inhered  in  methods  of  local  injection  of  anesthetic  agents. 

The  experience  reported  and  the  results  obtained  are  presented 
in  this  volume  with  absolute  impartiality,  yet  the  author's  individual 
conviction  is  unhesitatingly  asserted  in  the  treatment  of  such  an 
essential  question  as  the  choice  of  the  anesthetizing  agent.  This 
will  be  fully  appreciated  by  busy  practitioners  eager  to  avail  them- 
selves of  a  valuable,  trustworthy,  and  tried  method  without  incurring 
the  trouble,  expense,  and  risk  of  experimenting  with  a  host  of  stren- 
uously advertised  proprietary  preparations  before  arriving  at  a  definite 
choice.  The  author  advocates  novocain  and  its  solutions,  which,  after 
innumerable  experiments  with  all  available  anesthetizing  agents,  the 
majority  of  which  are  proprietary,  he  has  found  the  most  suitable 
and  safe.  Novocain,  after  having  been  the  subject  of  an  article  by  the 
translator  of  the  present  work,  entitled  "Recent  Studies  on  Novocain," 
was  unconditionally  endorsed  by  no  less  an  authority  than  Dr. 
Hermann  Prinz,  in  his  paper  on  "A  Rational  Method  of  Producing 
Local  Anesthesia,"  in  which  he  terms  novocain  as  "alone  fully  cor- 
responding to  every  one  of  the  demands  to  be  made  upon  a  local 
anesthetic."  Since  the  publication  of  these  papers,  novocain  is  daily 
being  discussed  most  favorably  in  American  medical  and  dental  litera- 
ture, in  full  substantiation  of  Fischer's  claim  that  if  the  details  of 
the  improved   technique   of  injection   as  laid   down  in  this   book  are 


followed,  novocain  will  rapidly  find  new  advocates  and  insure  for  the 
dental  operator  success  in  his  operations,  together  with  his  patients' 
hearty  appreciation.  A  local  anesthetic  of  known  chemical  composi- 
tion that  has  been  successfully  employed  in  nearly  a  million  cases 
by  leading  dental  and  general  surgeons  without  one  fatal  result,  or 
even  any  untoward  sequelae  whatever,  may  be  conservatively  said 
to   have   passed   the  experimental   stages. 

Various  other  methods  of  inducing  local  anesthesia  are  described, 
though  intentionally  not  elaborated  upon,  as  having  relatively  limited 
value,  the  author  being  satisfied  with  having  evolved  a  single  accurate 
method  conforming  to  the  most  rigorous  standards  of  modern  science, 
toward  the  perfection  of  which  many  prominent  investigators,  espe- 
cially of  the  Heidelberg  and  Berlin  universities,  have  cooperated. 
The  indications  and  contraindications  of  other  methods  of  anesthesia 
especially  by  cocain,  have,  however,  by  no  means  been  overlooked, 
and  a  valuable  gauge  is  thus  obtained  of  their  relative  merits  by  way 
of    comparison. 

Special  consideration  has  also  been  given  to  anesthesia  in  the  therapy 
of  inflammation  and  wounds,  to  adjuvant,  systemic,  and  sedative 
treatment,  to  the  manipulation  of  nervous,  debilitated,  or  sickly 
patients  and  of  children,  and  to  local  anesthesia  in  the  extirpation  of 
vital  pulps  and  in  obtunding  hypersensitive  dentin. 

The  publishers,  Messrs.  Lea  &  Febiger,  have  spared  no  effort  or 
expense  in  the  technical  execution  of  this  book,  and  the  wealth  of 
illustrative  material  incorporated  should  prove  a  most  practical  feature. 
The  translator  wishes  to  make  most  grateful  acknowledgment  of 
the  inspiration  and  invaluable  aid  given  by  Professor  Edward  C. 
Kirk,  D.D.S.,  Sc.D.,  Dean  of  the  Dental  Department  of  the  University 
of  Pennsylvania,  in  the  preparation  of  this  work.  His  thanks  are  also 
given  to  Mr.  A.  F.  Tilly  for  his  painstaking  work  in  the  preparation, 
and  to  his  wife  for  her  valuable  assistance  in  the  proof-reading  of  this 

^•olume. 

R.  H.  R. 

Philadelphia,  1912. 


CONTENTS 


Pi\RT    I 

MODERN   LOCAL  ANESTHETICS  AND   THEIR   APPLICATIONS 

Pain 17 

Brief  Historical  Review     .         .         .  .         .         .         .         .         ...         .21 

Local  versus  General  Anesthesia       .  .  .  .  .  .  .  .  .  .24 

Preliminary  Measures  in  Local  Anesthesia        ........        29 

The  Operator's  Duties,  29.     Anamnesia,  29.     Eroticism,  32. 

Agents  for  Local  Anesthesia      ...........        34 

Anesthesia  by  Freezing,  34.  Anesthesia  by  Pressure,  35.  Chemically  Active  Agents,  35. 
Solubility  in  Water,  36.  Toxicity,  36.  Cocain  and  its  Substitutes,  36.  Toxicity  of 
Cocain,  37.     Substitutes  for  Cocain,  39. 

Novocain  and  its  Solutions  ...........        40 

General  Effects  after  Absorption,  41.  Effects  of  Novocain,  42.  Opinions  Regarding 
Novocain,  42.  Novocain-suprarenin,  43.  Suprarenin,  43.  Stability  of  Suprarenin 
Solution,  44.  Action  of  Suprarenin,  44.  Toxicity  of  Suprarenin,  45.  Standard  Pipette, 
45.  No  Tissue  Lesions  from  Suprarenin,  46.  Dosage  of  Suprarenin,  46.  The  Injecting 
Solution,  46.  Isotonia,  47.  Non-isotonic  Preparations,  47.  Admixture  of  Thymol,  48. 
Antiseptic  Property  of  Thymol,  49.  Other  Effects  of  Thymol,  49.  Anesthesia  by 
Thymol,  49.  Thymol  as  Admixture  to  Novocain  Solution,  50.  Reduction  of  Body 
Temperature,  50.  Temperature  of  Solution,  51.  Ampoules,  51.  Nature  and  Manip- 
ulation of  Ampoules,  51.  Grades  of  Concentration  of  Solution,  52.  Solution  4. 
Producing  More  Pronounced  Anemia,  52.  Tablets  Contra-indicated,  53.  Sterility  of 
Tablets,  53.  Ampoules  Preferable  to  Tablets,  54.  Preparation  of  Solution,  55. 
Stability,  55.  Composition,  55.  Factors  Affecting  Successful  Administration  of  Injec- 
tion, 56.  The  Normal  Solution,  56.  Bottles,  56.  Braun's  Latest  Experiences  ^\^th 
Novocain  and  its  Solutions,  57.  Application  of  Local  Anesthesia  in  Surgerj-,  58. 
Advantages  of  Local  Anesthesia  in  Surgery,  60. 

Instrumentarium         .............        61 

The  Injection  Syringe,  62.  Hubs,  64.  Needles,  65.  Treatment  of  Needles,  65.  Local 
Action  of  Novocain,  72.  Breaking  of  Needle,  72.  Idiosyncrasy,  72.  Treatment  of 
Syringe,  66.  Ampoules,  66.  Preparation  of  Solution  for  Injecting,  66.  Stasis 
Bandage,  68. 

Disinfection  of  the  Field  of  Operation      .........        69 

Disinfection  of  Mucosa,  69.  Effect  of  lodin,  69.  Application  of  lodin,  70.  Sterilit}'  in 
Injecting,  70. 


X  CONTENTS 

PART    II 

INDICATIONS   FOR   LOCAL   ANESTHESIA 

Dangers  of  Local  Anesthesia      .  .  .  .  .  .  .  .  .        • . 

Ethyl  Chlorid,  72.      Drugs  for  Injection,  72.     Shock  and  Collapse,  73.     Antidotes  in 
Collapse,  73.     Postoperative  Pain,  74.     Therapeutic  Measures  in  Postoperative  Pain, 
75.     Postoperative  Hemorrhage,  77. 
The  Operator's  Responsibility    ........... 

Anamnesia,  79.     Harmlessness  of  Normal  Solution,  79. 
Accidents  after  Novocain  Injections  .......... 

Narcotic  Slumber  after  Novocain,   80.      To.xic  Action  of  Novocain,   81.      Hysterical 
Attacks  after  Novocain,  84. 
Indications  for  Local  Anesthesia        .......... 

Dental  Surgery,  85.       Dentinal  and   Pulpal  Anesthesia,  85.      Root  Treatment  under 
Anesthesia  in  One  Sitting  in  Cases  of  Pulpitis  Contraindicated,  86.    Injection  Suitable 
for  Dentinal  Anesthesia,  85.      Quinin,  88.      Chloral  Hj^drate,  89.      Anesthesia  with 
Subsequent  Preservation  of  Vital  Pulp  Stumps  Indicated,  91.     Pressure  Anesthesia,  91. 
Root  Canal  Treatment,  94.      Crown  and  Bridge  Work,  95.     Indications  in  General 
Disease,  95.     Individual  Judgment,  95.    Contraindications,  95.    General  Anesthetics, 
96.    Drugs  for  Injection,  96. 
Anesthesia  in  the  Therapy  of  Inflammation         ........ 

Practical  Experiences  in  the  Oral  Cavity,  97.  Tongue,  98.  Coryza,-98.  Lacerations, 
98.  Modifying  the  Process  of  Healing,  98.  Examples  from  General  Pathology,  99. 
Local  Processes,  99.  Combating  Local  Irritability,  100.  Effect  of  Sedatives,  loi. 
Effects  of  Anesthesia,  loi.  Duration  of  Painlessness,  loi.  Prophylactic  Treatment 
of  Timid  and  Sensitive  Patients,  102. 


PART    III 

TECHNIQUE   OF   LOCAL   ANESTHESIA 

Anatomical  Structure  of  the  Osseous  Frame  of  the  Ma.xill^e    .         .         .         .         .103 
Surfaces  of  MaxiUae,  103.    Posterior  Surfaces  of  Maxillary  Bones,  109. 

The  Inferior  Dental  or  Mandibular  Foramen    .  .  .  .         .111 

The  Minute  Structure  OF  THE  Alveolar  Process         .         .         .         .         .         .         .116 

Structure  of  Osseous  Substance,  116.  Structure  of  Alveoli,  118.  Transverse  Sections 
of  Jaws,  118.  Maxilla  and  Mandible,  118.  Sections  of  Maxilla  and  Mandible,  122. 
Details  of  Diffusion,  125. 

The  Nerve  SuTPLY  of  THE  Masticatory  Apparatus        .......       125 

Root  of  Trigeminal  Nerve,  126.  The  Ophthalmic  Nerve,  126.  Branches  of  Distribu- 
tion of  First  Division  of  Trigeminal  Nerve,  126.  The  Maxillary  Nerve,  128.  Branches 
of  Distribution  of  Maxillary  Nerve,  128.  The  Infra-orbital  Branch,  130.  The  Man- 
dibular Nerve,  130.  The  Mandibular  Nerve  with  Inferior  Dental  Nerve,  134.  Branches 
Constituting  the  Trigeminal  Nerve,  134.  Plexuses  of  Trigeminal  Branches,  135. 
Stimuli  Referred  by  Anastomoses,  136.  Communications  between  the  Divisions  of 
Trigeminal  Nerve,  Especially  the  First  and  Second  Divisions,  136. 


CONTENTS  xi 

Areas  of  Nerve  Supply  of  the  Masticatory  Apparatus       ......       137 

Superficial  Areas,  139.    Maxilla,  140.    Palatal  Surface,  142.    Mandible,  143. 
The  Minute  Distribution  OF  Nerves  IN  THE  Alveolar  Process  AND  the  Pulp       .  143 

Periosteum,  143.     Pulp,  143.      Sensibility  of  Dentin,  145.      Structure  of  Nerve  Fila- 
ments of  Pulp,  147.     Nerve  Supply  of  Vascular  Walls,  148. 
The  Technique  of  Local  Injection      ..........       149 

Mucous  Anesthesia     .............       149 

Injection  into  Mucosa,  151.    Maxilla,  154.    Buccal  and  Labial  Injection,  154.    Palatal 
Injection,  157.     Injection  at  Posterior  Palatine  Foramen,  158.     Injection  in  Anterior 
Palatine  Fossa  Contraindieated,  161.     Mandible,  164.     Injection  in  Gingival  Papilla 
in  Mandible,  164.    Injection  in  Mental  Fossa,  164.    Lingual  Injection,  165.     Mucous 
Anesthesia  in  Lower  Molars,  167.    Lingual  Injection  in  Lower  Molars,  167.    Anesthesia 
in  Inflammatory  Swelling,  167.     Anesthesia  with  Ethyl  Chlorid,  168.     Injection  in 
Swollen  Areas,  168.    Period  of  Waiting,  169.    Principles  of  Mucous  Anesthesia,  169. 
Conductive  Anesthesia         ............       169 

Injection  at   Maxillary  Tuberosity',   171.       Infra-orbital  Injection,   174.       Injection  in 
Inferior  Dental,  or  Oblique,  or  Mandibular  Foramen   (Mandibular   Injection),  176. 
Position  of  Syringe,  176.     Character  of  Tissues,  176.     Technique  of  Injection,  177. 
Insertion  of  Needle,  179.     Difficulties,  180.    Management  of  Needle,  182.    Injection 
of   Solution,    1 84.      Effect   of    Injection,   186.      Paralyzation  of   Buccal  Nerve,   186 
Injection  in  Mental  Foramen,  187.      Principles  of  Conductive  Anesthesia,  1S8. 
Extent  of  Anesthesia  Obtained  ...........      189 

Completion  of  Anesthesia  in  Maxilla,  189.     Anesthesia  in  Region  of  Maxillary  Tuber- 
osity,   189.      Anesthesia  in  Region  of  Infra-orbital  Foramen,    190.      Anesthesia  in 
Mandible,  190.     Anesthesia  by  Way  of  Inferior  Dental  Foramen,  191. 
Tables  for  Injection  Anesthesia  ..........       191 

Addition.\l  Explanation  of  Tables       ..........       194 

Conclusion 195 


LOCAL  ANESTHESIA  IN  DENTISTRY 


PART    I 

MODERN  LOCAL  ANESTHETICS   AND   THEIR 
APPLICATIONS 


PAIN 

From  time  immemorial  the  problem  of  the  prevention  of  pain 
has  engaged  earnest  attention  in  the  practice  of  the  heaHng  art,  and 
no  other  branch  of  medical  science  was  better  suited  and  more  capable 
of  striving  after  its  abolition  than  surgery.  Fostered  by  this  special 
branch,  dentistry  has  now  matured  into  a  fully  privileged  and  inde- 
pendent department,  after  having  received  numerous  tokens  of 
maternal  care  from  the  mother  science,  not  the  least  of  which  being 
the  great  inspiration  in  the  endeavor  to  attain  local  anesthesia. 

The  operations  in  the  oral  cavity,  so  extremely  painful  as  com- 
pared with  other  operative  interventions,  prompted  a  special  desire 
to  diminish  or  to  abolish  entirely  the  sensibility  of  the  teeth,  a  desire 
which  was  all  the  more  justiiied  as  the  general  enervation  accruing 
from  modern  civilization  was  daily  increasing.  Moreover,  the  destruc- 
tion of  the  teeth  is  assuming  most  alarming  proportions,  and  all  pos- 
sible means  of  inhibiting  this  universal  disease  should  be  studied. 

Pain  in  itself  is  a  phenomenon  wisely  instituted  by  Nature.  To  use 
Goldscheider's  words:  "Pain  makes  us  realize  that  some  external 
danger  is  threatening  which  we  may  still  avoid,  or  that  harm  has  already- 
been  done  to  the  body,  requiring  our  care  if  we  would  escape  more 


18  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

serious  consequences.  Pain  arises  as  a  warning  signal,  whenever  we 
are  exposed  to  such  conditions  of  life  as  by  their  continued  influence 
would  involve  general  disturbances  of  health.  Pain  appears  before  or 
simultaneously  with  the  outbreak  of  disease,  warning  man  that  his 
body  is  in  a  diseased  condition  and  requires  care.  Pain  occasioned  by 
physical  or  mental  fatigue  indicates  the  necessity  for  rest  and  recrea- 
tion. Pain,  the  symptom  of  organic  disease,  imperatively  urges  the 
patient  to  save  the  diseased  organ.  Pain  is  the  physician's  most 
powerful  assistant,  whose  demands  the  patient  follows  in  blind  obedi- 
ence, and  who  saves  the  physician  many  a  prescription,  many  an 
advice  as  to  diet  and  conduct.  Through  pain,  Nature  imposes  rest 
even  upon  the  most  strenuous;  it  dictates  idleness  to  the  most  energetic, 
and  forces  the  most  obstinate  to  abide  by  conditions  suitable  for  the 
diseased  body. 

"  Pain  is  a  harsh  but  useful  law  of  Nature.  But,  like  all  natural  laws, 
it  is  unyielding  in  its  consistency,  blind  in  its  disregard,  brutal  and 
cruel.  Pain  appears  not  only  in  the  guise  of  benevolent  warning,  but 
also  in  that  of  troublesome  torment.  Even  in  incurable  disease,  in 
afl^ections  in  which  the  realization  of  ill  health  is  useless  for  the  patient, 
inasmuch  as  no  one  can  control  the  disease,  pain  is  present,  ruthlessly 
destroying  all  enjoyment  in  life  without  offering  any  physical  advantage 
whatever  by  way  of  compensation.  In  the  most  dangerous  diseases 
pain  is  often  absent,  thus  lulling  the  patient  into  a  sensation  of  security, 
only  to  appear  and  call  for  abolition  by  artificial  means  after  the  patient 
has  undergone  an  operation  in  order  to  save  his  life.  Hence  it  is  only 
proper  that  we  physicians  should  combat  our  ally;  for  to  wipe  out 
pain  entirely  is  an  impossibility,  and  we  cannot  and  would  not  do 
without  it,  since  pain  is  necessary  not  only  as  a  monitor  in  the  combat 
against  the  hostile  powers  of  matter,  but  also  as  an  inspirer  to  ethical 
emotions.  For  it  is  chiefly  in  the  reminiscence  of  one's  own  pain, 
both  physical  and  mental,  that  love  and  active  charity  are  rooted." 

Pain  belongs  to  that  order  of  sensations  which  are  usually  termed 
conditions  or  general  sensations,  so-called,  such  as  tickling,  itching, 
hunger,  thirst,  nausea,  and  others.  They  are  all  distinguished  by  a 
high   degree  of   pleasurable   or  unpleasurable   sensation,  and   do   not 


PAIN  19 

inform  us  concerning  our  environment,  like  the  sensory  perceptions, 
but  above  all  attract  our  attention  to  the  altered  state  of  our  own 
body. 

Pain,  empirically,  can  originate  only  within  the  radius  of  the  cen- 
tripetal sensory  nerves  and  the  nerves  of  touch,  while  the  sensations  of 
other  sensory  nerves  are  perhaps  disagreeable,  but  never  really  painful. 
Sensations  of  pain  and  touch,  therefore,  are  different  degrees  of  the 
same  sensation;  a  light  stimulus  produces  the  sensation  of  touch  or 
pressure,  while  a  stimulus  intensified  beyond  the  maximum  produces 
pain.  Pain  is  caused  by  the  increase  of  a  stimulus  beyond  a  certain 
limit,  with  central  radiation  of  the  same  over  neighboring  nerve 
plexuses,  and  by  a  prolonged  duration  of  the  stimulus.  Besides,  a 
sufficient  sensibility  of  the  stimulated  tissue  area  is  required.  Hence 
the  intensity  and  the  duration  of  the  stimulus  exert  a  decisive  influence 
upon  the  character  of  the  irritation.  In  the  case  of  a  prolonged  stimulus 
the  irritations  are  probably  stored  in  the  sensory  ganglionic  cells,  result- 
ing in  a  consummation  of  individual  stimulative  impulses  producing 
the  affection  of  pain,  and  at  the  same  time  a  hyperalgesic  condition. 
Inflammatory  pain  is  probably  due  to  the  hyperalgesic  condition 
of  the  ganglionic  cells,  induced  by  the  continuous  duration  of  the 
stimulus. 

The  character  of  the  pain  may  vary  considerably.  According  to 
Erb,  by  the  admixture  of  sense  perceptions,  burning  pains  may  arise; 
by  localization  or  expansion,  pricking  pains;  by  the  change  of  the 
stimulative  process,  throbbing  pains.  "Their  intensity  is  greatly 
dependent  upon  psychic  factors,  and  it  is  the  greater  the  more  we 
abandon  ourselves  to  them,  while  diversion  and  will  power  mitigate 
even  exceedingly  unpleasurable  sensations.  Kant,  for  instance,  is  said 
to  have  overcome  the  torture  of  gout  by  concentrating  his  thoughts 
upon  a  definite  subject.  At  night,  after  the  continually  changing 
impressions  of  a  day  have  ceased  to  occupy  the  mind,  pain  is  felt 
all  the  more  intensely."     (Mangold.) 

Besides,  other  factors,  such  as  education,  character,  intelligence, 
nationality,  age,  sex,  and  general  health,  exert  a  considerable  influence 
upon  the  origin  and  manifestation  of  painful  aff'ections.     The  newly 


20  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

born  is  free  from  all  sensations  of  pain,  which  gradually  asserts  itself 
with  the  development  of  the  sensory  organs. 

Like  all  other  sensations,  that  of  pain  is  one  of  the  functions  of  the 
cerebral  cortex,  in  the  "sphere  of  physical  sensations"  of  which  the 
sensory  filaments  are  supposed  to  terminate.  If  the  tract  of  fibers 
radiating  from  the  cortical  region  is  interrupted  in  the  region  be- 
tween the  posterior  and  anterior  ends  of  the  thalamus,  complete 
anesthesia  of  the  opposite  half  of  the  body  ensues.  The  peripheral 
sensory  nerves  of  the  brain  and  spinal  column  within  the  spinal 
cord,  including  the  gray  substance,  are  to  be  considered  as  conductors 
of  painful  sensations.  The  sympathetic  nervous  system,  however, 
probably  does  not  possess  the  faculty  of  conducting  pain. 

The  end  organs  of  the  sensory  nerves  are  tuned  to  certain  forms  of 
stimuli,  and  conduct  these  farther  on  to  the  cerebral  cortex,  probably 
in  such  a  way  that  complicated  chemical  changes  proceed  from  cell  to 
cell,  and  non-physically  effective  stimuli  are  transmitted  by  the  cell. 

Stimuli  of  different  quality,  i.  e.,  mechanical,  chemical,  thermal, 
and  electric,  are  able  to  produce  painful  sensations  in  the  sensory 
end  organs,  i.  e.,  their  conducting  tracts.  A  sensation  of  pain  origin- 
ating in  the  cerebral  cortex  is  communicated  to  the  parts  of  the  body 
lying  outside  of  the  brain,  not  clearly  localized,  however,  but  vaguely 
circumscribed,  as  frequently  in  the  oral  cavity.  In  diseased  tissue  the 
irritability  is  generally  increased,  rarely  diminished.  Acute  inflam- 
mations, in  which  the  increase  in  blood  pressure  plays  an  important 
role,  tend  especially  to  produce  rapid  and  severe  irritations  of  the 
sensory  nerve  plexuses  involved,  -/.  e.,  hyperalgesia.  On  the  other  hand, 
local  disturbances  in  nutrition,  as,  for  instance,  loss  of  function  in  dental 
pulps  and  chronic  edemas,  may  produce  a  diminution  of  sensation, 
i.  e.,  hypalgesia. 

Besides  the  varied  distribution  of  the  sensory  nerve  plexuses,  the 
function  and  situation  of  an  organ  bear  an  important  relation  to  its 
irritability.  Muscles,  subcutaneous  cellular  tissue,  tendinous  tissue, 
cartilage,  and  abdominal  organs,  for  instance,  seem  to  possess  but  very 
slight,  if  any,  sensibility,  while  the  epidermis,  the  mucosa  of  the  oral 
and  nasal  cavities,  the  urethra,  the  periosteum,  and  the  perichondrium  ■ 


BRIEF  HISTORICAL  REVIEW  21 

are  very  sensitive;  the  bones  and  marrow  are  less  so,  and  the  mucosa 
of  the  stomach  and  the  intestinal  canal  from  the  esophagus  downward, 
the  lung,  and  the  brain  itself,  are  entirely  insensitive. 

Consequently  the  sensibility  to  pain  is  widely  distributed  in  the 
human  body,  and  this  fact  sufificiently  accounts  for  the  continuous 
efforts  of  practical  medicine  from  its  beginning  to  influence  this  prop- 
erty of  each  tissue  by  an  artificial  reduction  of  sensibility  before  opera- 
tive intervention.  By  these  efTorts  it  is  intended  to  produce  inhibition 
of  sensibility,  i.  e.,  anesthesia,  or  at  least  inhibition  of  painful  sen- 
sation, i.  e.,  analgesia.  This  condition  of  insensibility  can  be  produced 
partly  by  natural  means,  i.  e.,  reduction  of  the  normal  irritability 
of  the  sensory  nerves  as  during  profound  sleep  or  in  sickness,  or  by 
artificial  means,  -/.  c,  employment  of  narcotics,  such  as  chloroform, 
ether,  and  others,  of  drugs  such  as  cocain,  novocain,  etc.,  or  of 
hypnosis. 

BRIEF   HISTORICAL   REVIEW 

Among  all  peoples  and  in  all  eras,  efforts  more  or  less  successful 
have  been  made  to  discover  means  for  preventing  pain.  It  was,  how- 
ever, not  so  much  local  as  general  anesthesia  which  at  a  very  early 
period  appeared  specially  desirable,  and  was  to  be  produced  by  various 
means,  most  frequently  by  vegetable  extracts.  By  the  application 
of  narcotic  agents,  which  consisted  mostly  of  narcotizing  decoctions 
administered  before  the  operation,  such  as  the  mandrake  root  potion, 
attempts  were  made  to  produce  a  state  simulating  sleep,  during  which 
the  operative  intervention  was  carried  out. 

In  the  year  50  a.d.  Dioscorides  is  said  to  have  made  the  first  attempt 
to  produce  a  sort  of  anesthesia  by  pulverizing  the  Memphis  stone, 
mixing  it  with  vinegar  into  a  paste,  and  allowing  it  to  act  locally  upon 
the  skin  for  some  time  before  the  operation.  In  this  preparation  car- 
bonic acid  presumably  played  some  role,  being  liberated  in  the  mixture 
of  limestone  and  vinegar,  and  producing  cold,  thereby  effecting  a  slight 
anesthesia  in  the  skin  area  thus  treated. 

In  the  Middle  Ages  local  anesthesia  seems  to  have  fallen  into  oblixion 


22  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

entirely,  for  it  was  not  until  the  end  of  the  eighteenth  century  that 
James  Moore  suggested  that  by  compressing  nerve  trunks  as  well 
as  by  severing  them,  analgesic  areas  could  be  produced.  Owing 
to  the  numerous  anastomoses,  the  effect  naturally  was  but  a  limited 
one,  and  the  chief  aim  of  the  investigators  of  that  time  was  to  perfect 
the  methods  of  general  anesthesia. 

Not  until  1866  did  local  anesthesia  begin  to  come  into  its  own, 
being  supported  and  inspired  by  the  comparatively  successful  attempts 
of  Richardson  to  obtain  anesthesia  of  the  skin  by  means  of  the  ether 
spray,  the  application  of  which,  in  a  limited  degree,  is  considered  cor- 
rect practice  to  this  day.  Richardson,  who  was  a  pioneer  also  in  the 
field  of  general  anesthesia,  is  entitled  to  additional  credit  in  regard 
to  local  anesthesia,  for  he  drew  attention  to  the  great  value  of  this 
method,  and  succeeded  in  interesting  the  surgeons  of  the  day  in  his 
ideas. 

About  the  seventies  of  the  last  century  local  anesthesia  lay  dormant, 
like  all  the  other  fields  of  science  and  art,  until  it  was  awakened  into 
new  life  by  the  efforts  of  Roller,  Schleich,  Robson,  Corning,  Oberst,  and 
others.  At  the  Congress  of  Ophthalmologists  held  in  Heidelberg  in  1884, 
Koller  demonstrated  the  remarkable  anesthetizing  power  of  cocain, 
which,  after  its  action  had  been  readily  tested  by  many  authorities, 
quickly  sprang  into  general  popularity.  But  the  methods  of  appli- 
cation of  this  drug  were  not  sufficiently  tested,  and  consequently, 
especially  in  anesthesia  of  the  mucous  membrane,  frequent  fatalities 
occurred,  owing  to  the  toxicity  of  cocain,  until  Schleich  and  Reclus 
introduced  their  infiltration  anesthesia  by  means  of  considerably 
smaller  cocain  doses.  This  method  was  still  further  perfected  by  the 
extract  of  the  suprarenal  capsule,  which  was  recommended  in  connec- 
tion with  anesthesia  by  Braun  (see  p.  23). 

Conductive  anesthesia  {perineural  or  regional  anesthesia),  which  is 
used  so  successfully  today,  was  first  suggested  in  1885  by  Halstedt, 
who  instead  of  injecting  cocain  in  the  vicinity  of  the  tooth  to  be  anes- 
thetized, injected  it  at  the  trunk  of  the  inferior  dental  nerve,  from 
the  oral  cavity;  this  principle  was  applied  by  Kummer  and  Pernice 
in  anesthesia  of  the  toes  and  fingers. 


BRIEF  HISTORICAL  REVIEW  23 

Medullary  anesthesia,  which  is  also  very  popular  today,  and  which 
has  been  perfected  by  Bier,  was  known  as  early  as  1885  to  Corning, 
who  discovered  by  animal  experiments  that  the  lower  extremities 
became  insensible  after  anesthetization  of  the  spinal  cord  by  injection 
between  the  spinous  processes  of  the  lumbar  vertebrae. 

Many  scientists,  such  as  Schleich,  von  Mikulicz,  Braun,  Kocher, 
and  von  Eiselsberg,  worked  indefatigably  toward  the  further  develop- 
ment of  this  field,  striving  especially  to  do  away  with  the  toxic  effects 
of  cocain  on  the  heart  and  the  central  nervous  system  inherent  in  this 
drug,  despite  its  excellent  anesthetizing  action.  "In  no  instance  is 
it  justifiable  to  speak  of  cocain  mixtures  as  being  harmless;  in  their 
application,  therefore,  the  greatest  care  is  needed,  as  the  effects  of 
cocain  on  the  entire  organism,  especially  the  central  nervous  system, 
must  be  realized  constantly.  I  have  collected  records  of  a  great 
many  cases  in  which  serious  sequelae  from  this  drug  were  noted,  even 
disturbances  of  the  functions  of  the  brain  in  the  form  of  sexual 
affections."     (Ritter.) 

Substitutes  were  offered,  such  as  eucain  alpha  and  beta  (Silex), 
acoin  (von  Heyden),  holocain  (Tauber),  tropacocain  (Giesel),  ortho- 
form,  nirvanin  (Einhorn  and  Heinz),  anesthesin  and  subcutin  (Ritsert), 
stovain  (Fourneau),  alypin,  novocain  (Einhorn),  and  others.  All  these 
drugs  were  supposed  to  possess  the  anesthetizing  power  of  cocain  with- 
out its  toxicity.  Science  and  industry  made  unceasing  efforts  to  find 
an  ideal  preparation  for  the  purpose  of  local  anesthesia.  It  was  Braun 
especially  who  tried  to  compare  the  different  cocain  substitutes  in 
regard  to  their  specific  action.  He  showed  that  anesthesia  is  a  chemical 
process,  a  combination  of  the  anesthetic  with  the  cell  elements,  i.  e.,  the 
nerves  of  the  injected  area.  Contrary  to  Schleich,  he  considered  the 
physical  factors,  such  as  cooling,  difference  in  osmotic  pressure,  and 
direct  pressure  upon  the  nerves,  as  non-essential.  Above  all,  he 
emphasized  the  behavior  of  the  vessels,  proving  that  the  simultaneous 
vascular  contraction  at  the  place  of  injection  is  an  important  aid  in 
the  intensity  and  duration  of  anesthesia.  In  this  way  Braun  came 
to  combine  the  suprarenal  preparations  with  the  anesthetics,  which 
method  has  become  absolutely  indispensable. 


24  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

Of  the  greatest  importance  for  the  further  development  and  per- 
fection of  injection  anesthesia  was  the  discovery  of  the  anemizing  action 
of  the  solutions  of  suprarenal  extract,  which  were  offered  on  the  market 
under  the  names  of  adrenahn,  renoform,  suprarenin,  etc.  Their  chief 
property  consists  in  intensifying  the  action  of  cocain  or  suitable  sub- 
stitutes, when  injected  in  mixture  with  the  anesthetic  solution,  by  pro- 
ducing a  vigorous  contraction  of  the  bloodvessels  in  the  injected  area; 
thereby  not  only  the  absorption  of  the  anesthetic  is  retarded,  but, 
for  the  same  reason,  considerably  smaller  quantities  of  the  solution 
suffice  to  produce  an  equally  efficient  anesthesia  as  the  employment 
of  larger  doses  of  pure  cocain  or  novocain  solutions  would  afford. 
Especially  the  combination  of  novocain  and  suprarenin  (which  latter 
is  now  being  prepared  synthetically),  i.  e.,  the  so-called  novocain- 
suprarenin  mixture,  while  being  equally  potent,  is  less  toxic  than  the 
cocain-suprarenin  solution,  and  is  therefore  preferred  in  surgery  and 
dentistry,  which  fact  is  to  be  regarded  as  a  further  advancement  in 
the  progress  of  our  special  science. 

Local  anesthesia  by  injection  is  sure  to  become  soon  the  common 
property  of  dental  science,  owing  to  the  efforts  expended  by  many 
dentists  toward  its  general  adoption.  The  works  of  Biinte  and  Moral, 
Cieszynski,  Konrad  Cohn,  Eckstrom,  Euler,  Hiibner,  Luniatschek, 
Misch,  Moller,  Paul,  Peckert,  Port,  H.  Prinz,  ReinmoUer,  Reclus, 
Ritter,  Rosenberg,  Sachse,  Schaffer-Stuckert,  H.  Schroder,  Seitz, 
Sauvez,  Thiesing,  Viau,  Walkhoff,  Williger,  Ad.  Witzel,  and  many 
others  have  furnished  the  material  for  the  future  development  of  anes- 
thesia within  our  special  field,  and  it  will  be  the  duty  of  any  historian 
who  may  in  the  future  record  the  development  of  local  anesthesia  in 
dentistry  to  accord  these  men  full  credit  for  their  efforts. 


LOCAL  VERSUS  GENERAL  ANESTHESIA 

Before  taking  up  the  aims  of  modern  local  anesthesia  in  detail,  a 
few  preliminary  remarks  on  the  relationship  between  local  and  general 
anesthesia  may  be  in  place,  especially  since  we  dentists,  in  practising 


LOCAL   VERSUS  GENERAL  ANESTHESIA  25 

on  a  very  important  but  circumscribed  part  of  the  body,  are  vitally 
interested  in  treating  and  curing  the  organs  intrusted  to  our  care  in 
such  a  manner  that  no  damage  to  the  entire  organism  will  result. 
Therefore  the  question  of  the  relative  toxicity  of  local  anesthetics 
as  compared  with  that  of  general  anesthetics  is  of  great  interest. 

It  was  shown  in  our  brief  historical  review  that  the  earliest  results 
in  anesthesia  originated  in  the  domain  of  central  desensitization,  t.  e., 
general  anesthesia.  The  development  of  surgical  methods  of  operation 
was  closely  connected  with  the  problem  of  the  prevention  of  pain,  and 
these  two  movements  have  advanced  simultaneously. 

In  order  to  perform  a  difificult  and  tedious  operation  with  safety, 
the  surgeon  has  always  endeavored  to  paralyze  the  nervous  centres 
and  thus  to  abolish  completely  the  sensation  and  will  power  of  his 
patient;  in  other  words,  to  produce  general  anesthesia.  In  the  fields 
of  minor  surgery,  ophthalmology,  dentistry,  and  others,  in  which 
surgical  intervention  renders  such  an  aid  desirable,  investigators 
have  naturally  endeavored  to  evolve  methods  by  which  the  nerve 
endings  in  a  circumscribed  area  of  innervation  can  be  paralyzed, 
thereby  enabling  the  surgeon  to  operate  while  the  patient  is  fully 
conscious,  i.  e.,  under  the  influence  of  local  anesthesia.  By  local  anes- 
thesia we  mean  either  those  measures  by  which  only  the  terminal 
ramifications  of  the  nerves  in  a  definite  main  area  are  influenced, 
A.  e.,  mucous  anesthesia,  or  those  by  which  a  larger  nerve  trunk  is  inter- 
cepted directly  at  its  basis,  i.  e.,  conductive  anesthesia.  In  mucous 
anesthesia  the  nerve  endings  are  for  a  certain  length  of  time  incapaci- 
tated from  receiving  impressions,  while  in  conductive  anesthesia  a 
particular  nerve  trunk  is  prevented  from  conducting  an  impression. 

The  progress  of  local  anesthesia  has  been  enhanced  above  all  by 
general  anesthesia,  especially  by  the  want  of  perfect  safety  for  the 
patient's  life  which  still  inheres  in  the  latter  method.  Even  with  the 
exact  method  of  mixed  anesthesia,  so-called,  correctly  manipulated,  one 
fatality  in  7558  cases  is  still  to  be  expected.  At  the  last  Surgeons' 
Congress  of  1910,  Neuber  estimated  that  one  fatality  still  occurred 
in  2953  cases  of  chloroform  anesthesia.  The  very  many  errors  made 
in  general  anesthesia,   and    the   frequent    injudicious  employment   of 


26  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

general  anesthesia  when  so  many  methods  of  local  anesthesia  are 
available,  are  additional  and  important  factors  in  furnishing  a  special 
record  of  fatalities  in  addition  to  the  above  regular  statistics.  Unfor- 
tunately, general  anesthesia  has  very  frequently  been  induced  for 
minor  interventions,  such  as  tooth  extractions,  thus  causing  fatalities 
in  an  indirect  way.  General  anesthesia,  moreover,  requires  prepara- 
tions which  are  considered  by  most  patients  as  decidedly  disagreeable, 
and,  moreover,  it  is  often  followed  by  serious  after-effects. 

Even  though  the  operative  measures  in  inducing  local  anesthesia 
may  inspire  him  with  a  certain  fear  and  anxiety,  the  patient,  being 
fully  conscious  of  all  the  steps  during  the  entire  operation,  enjoys  the 
great  advantage  of  not  being  exposed  to  any  vital  danger  whatever, 
owing  to  the  high  status  of  perfection  of  local  anesthesia  as  compared 
with  that  of  general  anesthesia.  Fatalities  due  to  local  anesthesia 
have  been  reported  alone  after  the  application  of  cocain.  The  methods 
of  local  anesthesia  as  practised  for  interventions  in  the  eye,  mouth, 
nose,  ear,  and  the  extremities,  undoubtedly  involve  but  little  proba- 
bility of  vital  danger  for  the  patient,  especially  if  these  methods  are 
practised  by  skilled  hands. 

The  great  danger  in  operations  on  the  thyroid  gland,  for  instance, 
which  involve  serious  interference  with  the  cardiac  nerves,  and  which, 
in  combination  with  general  anesthesia,  are  liable  to  produce  syncope 
of  the  heart,  is  sufficiently  well  known,  and  has  induced  surgeons  to 
perform  thyroid  extirpation  under  local  anesthesia.  The  application 
of  local  anesthesia  in  dentistry  is  demanded  all  the  more  imperatively 
as  the  very  nature  of  the  field  of  operation  in  every  respect  indicates 
local  intervention. 

A  knowledge  of  the  sensibility  and  the  nerve  supply  of  the  individual 
tissues  is  of  importance  in  the  application  of  local  anesthesia.  The  skin 
and  the  mucosa,  as  well  as  the  periosteum,  the  pericementum,  the  pulp, 
and  the  dentin  are  sensible  to  pain  in  a  degree  to  which  the  muscles 
will  react  far  less  readily.  A  conscientious  and  experienced  operator, 
when  considering  all  these  factors,  will  be  able  to  operate  painlessly 
provided  that  the  patient  faithfully  and  patiently  follows  his  directions. 
Here  we  touch  upon  a  question  of  great  importance  in  dental  local  anes- 


LOCAL   VERSUS  GENERAL  ANESTHESIA  27 

thesia,  i.  e.,  that  of  educating  the  patient  to  have  faith  in  the  operator. 
Some  nervous  persons  regard  the  thought  of  being  operated  upon  under 
a  local  anesthetic  while  fully  conscious  as  far  more  formidable  than  the 
struggle  under  a  general  anesthetic,  and  it  requires  calmness  and  dis- 
cretion on  the  part  of  the  operator  to  persuade  them  to  submit  to  local 
anesthesia.  It  is  then  the  operator's  duty  to  justify  fully  this  reluc- 
tantly granted  confidence  of  the  patient  by  doing  all  within  his  power 
and  skill  to  perform  a  perfectly  painless  operation.  If  he  fails,  the 
patient  will  lose  forever  his  self-control  gained  by  the  operator's 
mental  suggestion,  and  will  thenceforth  firmly  advocate  general 
anesthesia.  In  local  anesthesia  especially  remarkable  results  can 
be  obtained  by  mental  suggestion,  and  in  our  hospital  and  private 
practice  we  have  had  many  a  patient  who  was  induced  by  such  mental 
influence  to  submit  to  a  local  anesthetic. 

In  regard  to  technique,  local  anesthesia  offers  the  great  advantage 
of  .rendering  the  aid  of  an  assistant  unnecessary;  on  the  other  hand,  the 
presence  of  a  third  person,  an  assistant  or  a  woman  attendant,  is  recom- 
mendable  for  social  reasons.  Several  cases  of  sexual  hallucinations 
following  the  injection  of  cocain  solutions  locally  in  extractions  have 
been  reported,  in  which  the  operator  had  difficulty  in  clearing  himself 
owing  to  the  absence  of  a  third  person,  who  could  easily  have  testified 
to  his  innocence. 

"  It  has  therefore  been  established  as  a  general  rule  that  neither  the 
physician  nor  the  dentist,  without  urgent  reasons,  should  induce  anes- 
thesia when  alone,  but  that  a  medical  assistant,  or  at  least  another 
person,  should  be  present.  The  presence  of  a  witness  is,  indeed,  impera- 
tive, owing  to  the  additional  fact  that  frequently  during  the  application 
of  anesthetics  hallucinations  or  dreams  occur  which  deceive  the  patient, 
the  operator  becoming  consequently  involved  in  a  most  disagreeable 
situation.  Especially  in  treating  patients  below  the  age  of  twenty-one 
great  care  is  necessary,  since  every  operative  step  which  is  undertaken 
without  the  permission  of  his  guardians  may  possibly  be  denounced 
as  malpractice.  A  minor  has  no  legal  right  to  any  serious  decision, 
and  for  surgical  operations,  therefore,  even  for  the  most  insignificant 
intervention  in  the  human  body,  the  consent  of  the  parent,  guardian, 


28  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

or  legal  representative  is  necessary.  Dentists  should  take  the  greatest 
possible  care  in  this  respect  when  a  serious  oral  operation  or  anesthesia 
is  involved,  and  injections  even  of  a  local  anesthetic  should  never  be 
made  in  minors  without  previous  agreement.  In  such  cases  a  plea 
of  professional  custom  would  hardly  be  accepted,  the  legal  represen- 
tative's special  consent  being  always  required."     (Ritter.) 

Local  anesthesia  offers  an  additional  and  important  advantage  over 
general  anesthesia,  inasmuch  as  local  anesthetics  can  be  very  readily 
applied  and  require  no  lengthy  preparation  either  on  the  physician's 
or  on  the  patient's  part.  This  is  extremely  valuable,  especially  for 
ambulatory  dental  practice,  in  a  big  city  as  well  as  in  the  country, 
in  the  dentist's  surgery  as  well  as  in  the  patient's  home.  The  produc- 
tion of  general  anesthesia  under  difficult  conditions  or  in  unsuitable 
surroundings  ofifers  infinitely  greater  disadvantages,  and  its  final 
success  stands  in  no  proportion  to  that  which,  in  dental  operations 
under  local  anesthesia,  can  be  obtained  by  a  skilled  hand  almost  at 
any  time,  in  any  place,  and  in  almost  any  patient.  To  be  sure,  the 
dentist  must  have  sufificient  experience  to  cope  with  any  difficulties  that 
may  arise  in  any  case;  he  must  fully  master  the  technical  methods  of 
preventing  pain,  especially  our  modern  injection  anesthesia;  he  must 
know  exactly  the  pharmacological  and  physiological  effects  of  his 
solution,  and,  above  all,  he  must  be  able  to  diagnosticate  the  general 
condition  of  each  patient  in  order  to  treat  him  according  to  individual 
requirements;  for  there  is  no  doubt  that  the  resistance  of  the  organism 
in  absorbing  injected  solutions  largely  determines  the  method  of  pro- 
cedure. Thus  the  dentist  can  use  a  smaller  quantity  of  solution  in 
greatly  anemic  or  tubercular  patients,  and  reduce  the  dose  of  the 
suprarenal  extract  which  is  dangerous  for  the  heart,  without  jeopard- 
izing his  success  thereby.  In  such  patients  often  only  very  superficial 
general  anesthesia  is  applicable,  the  patient  even  then  being  in  constant 
danger,  and  pain  being  only  partially  abolished.  The  application  of 
local  anesthesia  is  consequently  far  more  advisable,  guaranteeing,  as 
it  does,  perfect  success  and  the  patient's  full  appreciation;  for  it  must 
not  be  overlooked  that  with  every  successful  operation  we  gain  friends 
and  advocates  of  local  anesthesia  among  our  patients,  who  will  aid 


PRELIMINARY  MEASURES  IN  LOCAL  ANESTHESIA  29 

in  popularizing  a  method  which  is  worthy  of  becoming  the  common 
usage  with  all  dentists.  To  what  extent  general  surgery  has  succeeded 
in  its  tendency  to  replace  general  by  local  anesthesia  may  be  seen  from 
Braun's  report,  which  will  be  given  later  (see  p.  58),  and  which  we 
would  specially  emphasize. 


PRELIMINARY  MEASURES  IN  LOCAL  ANESTHESIA.     THE 
OPERATOR'S  DUTIES 

After  having  shown  that  the  method  of  local  anesthesia  is  not  only 
indicated,  but  imperatively  demanded  of  the  dentist,  the  details 
of  this  procedure  will  be  considered.  While  general  anesthesia,  to  be 
correctly  induced,  always  requires  elaborate  preparations,  the  induction 
of  local  anesthesia  necessitates  only  certain  measures,  which  will  be 
discussed  in  the  following  paragraphs: 

Anamnesia. — After  obtaining  as  accurate  an  anamnesia  as  possible, 
which  can  be  best  and  most  tactfully  secured  in  unforced  conversation, 
the  operator  should  inform  himself  about  the  patient's  general  physical 
condition.  Special  attention  is  to  be  devoted  to  weakly  and  anemic 
persons  and  to  patients  who  are  convalescent  from  serious  infectious 
disease,  such  as  influenza,  also  to  physically  depressed  or  nervously 
irritated  individuals,  and  hystericals — all  of  whom  require  special  care 
in  painful  operations.  In  such  patients  the  normal  quantity  of  an 
anesthetic  which  may  be  safely  applied  in  strong  and  healthy  persons 
produces  more  or  less  toxic  effects,  which,  as  a  rule,  can  be  avoided 
by  lessening  the  dose  to  be  injected.  By  his  calm  self-possession  in 
asking  questions,  and  his  winning  manners  by  which  he  can  dissipate 
the  patient's  fear,  the  operator  can  suggest  to  the  patient  sufficient 
composure  and  confidence  as  to  enable  the  operation  to  be  begun. 
The  patient's  psychic  composure  is  of  great  necessity  in  the  first  insertion 
of  the  needle,  which  is  sometimes  technically  complicated,  and  can  be 
accomplished  only  under  the  proper  psychic  influence  on  the  part  of  the 
operator.  The  operator's  success  is  assured  as  soon  as  he  has  intro- 
duced the  needle  in  the  desired  position.     If  the  patient  feels  little  or 


30  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

nothing  of  the  puncture  of  the  needle,  he  will  quickly  gain  full  confidence 
in  local  anesthesia,  and  remain  calm  during  the  remainder  of  the  opera- 
tion, provided  that  the  operator  by  his  technical  skill  succeeds  in  fully 
attaining  the  expected  effects  from  his  measures. 

Even  if  inevitable  pain  arises,  the  patient  will  be  willing  to  bear  it,  pro- 
vided the  operator  has  beforehand  hinted  sensibly  at  such  a  possibility. 
It  may  happen,  for  instance,  during  operations  that  deeply  lying  areas 
of  the  alveoli  have  not  been  reached  by  an  injection  in  the  mucosa 
after  severe  fracture  of  the  root,  and  have  remained  sensiti^•e.  Or 
the  operator  may  introduce  a  hook  or  scalpel  in  an  insufficiently 
anesthetized  portion  of  the  mucosa,  thus  causing  sudden  pain.  It  is 
part  of  the  art  of  the  modern  anesthetist  to  know  and  consider  all 
imaginable  conditions,  to  reckon  with  all  the  factors  involved,  and  thus 
to  produce  the  desired  painlessness.  Every  operator  must  be  his 
own  severe  critic,  and  must  know  how  highly  he  can  estimate  his  own 
ability  and  experience,  and  how  far  he  can  trust  his  own  skill.  He 
must  be  certain  whether  he  is  technically  able  to  produce  such  anes- 
thesia as  the  conditions  may  demand,  or  whether  he  should  make 
certain  concessions  by  notifying  the  patient  of  the  possibility  of  pain. 
This  does  not  necessarily  discourage  the  patient,  rather  it  contributes 
to  inspire  confidence.  Such  a  candid  admission,  scientifically  justified 
as  it  is,  is  the  more  appreciated  the  greater  the  operator's  skill 
and  ease,  and  it  exemplifies  modesty,  which  unfortunately  is  rarely 
met  with.  The  habit  of  some  practitioners  to  guarantee  the  patient 
absolute  painlessness — a  feature  which  unfortunately  is  still  being 
adhered  to  in  the  advertisements  of  a  certain  class  of  dental  practi- 
tioners— cannot  be  condemned  sharply  enough,  and  must  be  rebuked 
as  being  unprofessional  and  unscientific. 

A  correct  reserve  on  the  part  of  the  operator  is  all  the  more  in  place, 
as  besides  preventing  pain  he  is  also  obliged  to  perform  the  operation, 
and  therefore  faces  a  specially  difficult  task.  Even  though  the  opera- 
tion be  a  minor  one,  the  operator  nevertheless  has  to  exhibit  great 
technical  ability,  alertness  in  observation,  presence  of  mind,  and 
determination.  Thus,  for  instance,  the  problem  of  direct  anesthesia 
of  the  dentin  and  pulp  still  remains   unsolved,  and  it  requires  most 


PRELIMINARY  MEASURES  IN  LOCAL  ANESTHESIA  31 

subtle  and  clever  manipulation  to  perform  this  operation  successfully 
in  so  minute  an  organ  as  the  pulp. 

Pulse  and  respiration  must  also  be  watched  in  order  that  disagree- 
able accidents  interfering  with  the  operation,  such  as  dizziness,  col- 
lapse, spasms,  etc.,  may  be  recognized  by  their  symptoms  and  pre- 
vented. As  experience  shows  that  such  accidents  occur  frequently 
in  patients  affected  with  heart  trouble  or  some  constitutional  disease, 
every  dentist  ought  to  be  able  to  make  an  examination  of  the  heart 
and  lungs  by  auscultation  and  percussion,  a  requirement  which  should 
be  included  in  the  dental  curriculum. 

Besides  realizing  the  importance  of  general  health,  the  operator  has 
to  consider  the  local  condition  of  the  diseased  area,  which  frequently 
determines  the  correct  selection  of  the  method  to  be  employed  for  the 
prevention  of  pain.  In  cases  of  pericementitis  or  in  putrescent  pro- 
cesses, local  anesthesia  of  the  mucosa  frequently  produces  severe  pain 
upon  insertion  of  the  needle  and  during  injection,  the  final  effect  being 
very  unsatisfactory.  In  such  conditions  conductive  anesthesia  is 
properly  indicated,  also  in  all  cases  specially  suitable  for  this  method 
for  anatomic  or  local  reasons.  The  question  of  efficient  asepsis  must 
also  be  considered,  being  of  the  utmost  importance  in  local  injection 
anesthesia. 

Thus  the  operator,  who  incidentally  must  be  a  capable  anesthetist, 
assumes  great  responsibilities,  since  by  faulty  manipulation  he  may 
endanger  the  patient's  health,  even  life,  and  is  held  responsible  for 
any  damage  caused  by  negligence.  The  danger  increases  Avith  the 
difficulty  of  the  method,  and  the  demands  for  a  perfect  mastery  of  the 
technique  increase  correspondingly.  Although  the  law  does  not 
require  the  presence  of  a  skilled  assistant  in  local  anesthesia  cases, 
the  operator  is  by  no  means  held  less  responsible.  Only  if  it  is 
proved  beyond  doubt  that  he  has  fulfilled  his  duty  in  every  respect 
will  he  be  completely  exonerated  in  case  of  unfortunate  accident. 

It  is  the  operator's  further  duty  to  keep  an  accurate  record  of  the 
patient,  the  disease  observed,  and  the  therapeutic  measures  employed. 
The  method  of  injection  and  the  quantity  of  solution  injected  must  be 
noted,  also  any  phenomena  occurring  during  the  operation.     Such  a 


32  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

conscientiously  kept  record  will  in  case  of  unlooked-for  accident  go  far 
toward  substantiating  the  operator's  realization  of  responsibility  and 
favorably  influencing  the  verdict  in  case  of  accident.  The  presence 
of  a  third  person  who  may  serve  as  witness  is  a  valuable  safeguard, 
especially  in  cases  where  patients,  even  under  local  anesthesia,  claim 
to  have  experienced  sexual  affections  and  accuse  the  operator .  of 
immoral    attempts. 

Eroticism. — Sexual  affections  that  may  arise  are  always  due  to  the 
strong  general  action  of  the  anesthetizing  agent  upon  the  central 
nervous  system,  producing  a  series  of  lascivious  thoughts  and  concep- 
tions similar  to  those  produced  by  nitrous  oxid  anesthesia.  In  female 
patients  such  hallucinations  very  frequently  affect  the  genitals,  and  in 
neuropathic  and  hysterical  persons,  though  they  be  fully  conscious,  per- 
sist as  real  sensations  which  are  wrongly  interpreted.  That  conditions 
simulating  sleep  may  occur  in  connection  with  local  anesthesia  the 
writer  has  personally  noted  in  one  case  of  novocain  injection.  In  this 
connection  the  case  published  by  Korner  should  be  cited:  A  lady 
had  been  locally  anesthetized  with  ethyl  chlorid  for  the  purpose  of 
extraction  of  a  tooth,  and  though  she  had  remained  conscious,  claimed 
to  have  been  assaulted  during  the  operation.  Owing  to  the  presence 
of  several  persons  who  had  witnessed  the  operation  from  beginning 
to  end,  it  was  easy  to  explain  this  unpleasant  incident. 

"It  is  a  fact,  known  to  the  physician  and  dentist  alike,  that  all 
anesthetics  may  produce  erotic  dreams.  This  is  true  not  only  of 
the  agents  employed  in  general  anesthesia,  but,  according  to  pub- 
lished records  and  my  own  experience,  also  of  local  anesthetics, 
especially  cocain.  One  of  the  first  to  publish  a  comprehensive  work 
on  cocain  anesthesia  in  operations  in  the  oral  cavity  was  the  late 
Professor  Dr.  Witzel.  He  states  that  in  one  of  his  women  patients, 
in  whose  gums  he  had  injected  eight  drops  of  his  cocain  solution  (0.08 
cocain),  sexual  excitement  was  noted  five  minutes  after  the  extraction. 
Shortly  after  the  introduction  of  cocain  in  dentistry  I  applied  this 
agent  myself  in  subcutaneous  injections,  but  abandoned  its  use  after 
having  experienced  all  kinds  of  disagreeable  accidents,  above  all  syn- 
copes and  severe  hemorrhages  from  extraction  wounds  due  to  failure 


PRELIMIXARY  AIEASURES  IX  LOCAL  ANESTHESLA  33 

of  the  bloodvessels  to  contract  normally  after  the  injection,  also 
lascivious  speeches  and  gestures,  even  confused  narrations. 

"It  is  only  within  recent  years,  since  the  adoption  of  the  so-called 
cocain  mixtures,  that  I  have  readopted  such  injections  in  my  practice. 
But  even  in  these  cocain  mixtures,  which  generally  contain  an  ad- 
mixture of  adrenalin  (suprarenal  extract),  these  symptoms  of  sexual 
excitement  appear  in  both  male  and  female  patients,  especially  the 
latter,  and  I  should  therefore  advise  every  operator  never,  if  possible, 
to  administer  local  anesthetics  to  female  patients  in  the  absence  of 
witnesses.  In  his  recent  work  on  The  Sequelce  and  Secondary  Effects  of 
Local  Anesthetics  in  Dental  Operations,  Dr.  Dorn,  who  is  to  be  regarded 
as  an  authority  on  this  subject,  agrees  with  Lewin  that  the  after- 
effect of  cocain  anesthesia  does  not  depend  upon  the  quantity  of  the 
drug  injected,  and  that,  as  has  been  verified  by  the  writer's  own  ex- 
perience, even  very  minute  doses  suffice  to  produce  toxic  secondary 
effects.  Dorn  further  reports  that  in  women,  after  the  application  of 
cocain,  erotic  conditions  may  occur,  sometimes  even  without  any  dis- 
turbance of  consciousness,  and  I  myself  can  verify  these  observations, 
which  are  very  important  for  the  case  under  consideration. 

"Another  case  reported  by  Dorn  is  very  important:  A  girl,  aged  twenty 
years,  shortly  after  an  operation  under  cocain,  lapsed  into  a  condition 
of  tremendous  excitement,  respiration  being  considerably  accelerated, 
pulse  102,  and  made  voluptuous  motions  with  her  lips,  without  notably 
reacting  upon  being  spoken  to.  After  having  remained  in  this  condi- 
tion of  mental  distraction  and  great  excitement  for  about  ten  minutes, 
she  gradually  regained  consciousness,  and  explained  that  she  had 
dreamed  of  her  fiance. 

"How  closely  cocain  intoxication  and  hysteria  may  be  related,  and 
how  dangerous  this  combination  may  be  for  the  operator,  is  proved  by 
the  following  case  published  by  Hentze:  A  young  woman  had  a  tooth 
extracted  in  the  clinic  under  local  anesthesia.  She  showed  symptoms 
of  cocain  intoxication  and  hysterical  fits,  but  soon  recovered  and 
returned  home.  Soon  afterward  the  assistant,  who  had  been  present 
at  the  operation,  and  whom  she  had  not  known  e\-en  b\'  name,  received 
love  letters  from  the  woman,  which  remained  unanswered.    Three  davs 


34  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

following  the  operation  the  patient  committed  suicide  by  shooting, 
after  having  written  to  the  assistant  that  she  intended  to  take  her 
life  unless  she  received  a  reply.  It  was  ascertained  afterward  that 
the  woman  was  engaged  to  some  other  man."     (Ritter.) 


AGENTS  FOR  LOCAL  ANESTHESIA 

After  these  general  considerations,  the  question  arises  by  what 
means  a  satisfactory,  safe,  and  effective  local  anesthesia  may  be  ob- 
tained. There  is  a  great  number  of  anesthetics  which  have  been 
applied  in  various  ways  more  or  less  successfully,  but  few  of  these 
deserve  serious  consideration  in  view  of  the  severe  specifications 
demanded  of  an  up-to-date  anesthetic.  Like  narcotics,  almost  all 
anesthetics  are  poisonous  to  the  living  human  organism,  and  their 
toxic  effects  upon  the  general  system  must  therefore  be  checked 
by  specially  suitable  dosage  and  solution. 

Anesthesia  by  Freezing. — There  are  chemical  agents,  such  as  cocain, 
which  produce  analgesia,  while  the  physical  methods  of  anesthesia 
by  freezing  and  pressure  are  chiefly  localized  in  their  effect.  The 
latter  methods  have  been  practised  the  longest.  Anesthesia  by  freez- 
ing is  based  on  depriving  the  tissues  of  as  much  heat  as  possible 
by  the  application  of  congealing  agents,  of  which  the  ether  spray  is 
generally  known,  thereby  producing  a  condition  of  analgesia  in  the 
tissues.  Owing  to  the  great  loss  of  heat,  the  tissues  of  the  living 
organism  are  changed  into  a  solid  state.  The  tissue  fluids,  blood  and 
lymph,  being  of  an  aqueous  nature,  solidify  like  water  during  frost, 
affecting  the  sensory  nerve  endings  in  such  a  way  as  to  render  them 
incapable  of  transmitting  impressions  to  the  central  organ.  The  sense 
of  touch  is  thereby  affected  but  little  or  not  at  all,  so  that  anesthesia 
by  this  means  consists  not  so  much  in  a  deadening  of  the  entire  complex 
of  senses  as  in  the  abolition  of  the  sense  of  pain,  i.  e.,  analgesia. 

The  epidermis  is  permeable  to  gaseous  bodies,  the  mucosa  even  more 
so.  The  ethyl  chlorid  gas  which  is  developed  upon  application  to  the 
warm    surface    of     the    mucous    membrane    penetrates    the    epithelial 


AGENTS  FOR  LOCAL  ANESTHESIA  35 

retiform  interstices,  the  tissue  pores  and  glands,  aided  by  the  high 
pressure  caused  by  the  deprivation  of  heat.  A  rapid  anesthesia  of 
the  nerve  elements  affected  is  thus  produced,  which,  however,  usually 
wears  off  just  as  rapidly. 

Anesthesia  by  Pressure. — Besides  freezing,  the  compression  of  nerve 
tracts  has  long  been  employed  for  the  production  of  a  sort  of  anal- 
gesia. By  firmly  tying  a  portion  of  the  body,  as,  for  instance,  the  arm, 
the  sensation  of  pain  can  be  notably  diminished,  yet  not  completely 
abolished.  In  dentistry  the  simple  method  of  anesthesia  by  pressure 
is  still  applied  in  obtunding  sensitive  dentin  or  exposed  pulps.  How 
far  this  procedure  is  satisfactory  will  be  considered  in  the  special 
discussion  of  dentinal  anesthesia. 

Schleich  adopted  the  principle  of  physical  pressure  for  the  production 
of  anesthesia  by  completely  filling  the  tissues  to  be  obtunded  with 
injected  fluid,  and  producing  an  infiltration,  an  artificial  edema.  The 
pressure  and  tension  produced  in  this  way  incapacitates  the  affected 
nerve  filaments  to  convey  stimuli.  Schleich  employed  for  this  purpose 
very  weak  cocain  solutions,  at  the  same  time  aiming  to  produce  a 
chemical  effect,  thus  utilizing  a  combination  of  physically  and  chemi- 
cally active  agents.  Although  to  but  a  limited  degree,  anesthesia  of 
the  mucosa  in  the  alveolar  region  is  also  based  upon  a  combination 
of  pressure  and  chemical  action  of  the  solution,  the  latter  being  of 
decisive  importance.  In  their  action  the  injection  anesthetics  have 
reached  such  a  high  degree  of  perfection  that  today  they  dominate 
the  entire  technique  of  dental  local  anesthesia. 

Chemically  Active  Agents. — All  the  prevalent  anesthetics  of  today 
represent  organic  chemical  combinations  which  are  applied  upon  or 
within  the  tissues  in  the  form  of  suitable,  generally  aqueous  solutions. 
For  the  anesthetization  of  mucous  surfaces  high  per  cent,  cocain 
solutions  or  concentrated  novocain  solutions  are  employed,  while 
for  injection  into  the  connective  tissue  dilute  solutions  are  always 
indicated.  In  the  external  application  upon  the  oral  mucosa  a  super- 
ficial anesthetizing  effect  is  produced  by  the  lymphatic  fluid,  which  is 
distributed  through  the  tissue,  readily  seizing  the  salts  introduced, 
dissolving  them  and  carrying  them  off  to  deeper  strata.     The  super- 


36  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

ficial  situation  of  the  sensory  nerve  endings  distributed  closely  under 
the  epithelium  greatly  favors  this  action. 

Solubility  in  Water. — As  the  tissue  juices  are  themselves  of  an  aqueous 
nature,  only  aqueous  solutions  of  anesthetics  are  effective,  especially 
since  their  anesthetizing  power  is  directly  proportional  to  their  solu- 
bility in  water.  For  this  reason  salts  that  are  very  readily  soluble  ia 
water,  such  as  cocain,  eucain,  tropacocain,  novocain,  and  others,  yield 
the  best  results,  especially  when  these  salts  are  formed  with  acids,  in 
order  to  increase  their  solubility  in  water,  in  the  form  of  hydrochlorids. 

Toxicity. — The  toxicity  of  the  anesthetizing  salts  is  reduced  to  a 
minimum  by  various  measures.  The  concentration  of  the  solution 
is  restricted  to  certain  limits,  and  the  solution  itself  reacts  in  the 
human  system  according  to  certain  fixed  laws.  If  the  patient  is  given 
a  solution  of  sufficient  strength  by  the  mouth,  a  much  too  rapid  and 
extensive  absorption  takes  place,  generally  followed  by  severe  toxic 
symptoms.  The  same  quantity,  on  the  other  hand,  is  very  well  tol- 
erated subcutaneously,  and  is  generally  absorbed  without  any  local 
disturbances.  Nevertheless,  even  in  subcutaneous  application  the 
maximal  dose,  which  varies  with  different  salts,  must  not  be  exceeded, 
for  most  anesthetics,  besides  their  action  upon  the  nerve  endings, 
produce  toxic  conditions  in  the  central  nervous  system  by  way  of  the 
circulatory  system.  While  partly  paralyzing  the  brain  and  its  special 
centres,  they  exert  an  irritating  and  destructive  influence  which  is  the 
greater  the  larger  the  quantities  introduced  into  the  blood.  Besides, 
secondary  effects  may  occur,  which  are  specific  for  each  individual 
drug,  so  that  the  conscientious  operator  has  every  reason  to  familiarize 
himself  to  the  smallest  detail  with  the  efl^ect  of  the  anesthetic  employed. 

Cocain  and  its  Substitutes.  —  Of  the  innumerable  anesthetics  the 
following  should  be  mentioned:  Cocain  and  its  substitutes,  i.  e.,  novo- 
cain, eucain  alpha  and  beta,  acoin,  tropacocain,  holocain,  nirvanin, 
anesthesin,  orthoform,  stovain,  alypin,  yohimbin,  and  aneson,  all  of 
which,  with  a  few  exceptions,  have  been  discarded  after  having  been 
in  vogue  but  a  short  time.  Cocain,  being  the  original  preparation, 
has  tenaciously  held  its  own  despite  the  alarming  sequelae  which  have 
frequently  been  observed.     It  possesses,  however,  such  a  great  many 


AGENTS  FOR  LOCAL  ANESTHESL4  37 

disadvantages,  especially  a  specifically  high  toxicity,  that  its  employ- 
ment is  being  limited  more  and  more,  greatly  to  the  benefit  of  suff^ering 
humanity. 

Toxicity  of  Cocain. — ''  Transitory  disturbances  in  brain  function, 
chiefly  conditions  of  excitement,  occur  in  certain  patients  either  very 
soon  or  as  late  as  two  hours  after  the  introduction  of  cocain.  Some 
patients  chat  with  trembling  voice,  or  exhibit  symptoms  simulating 
intoxication.  Others  talk  confusedly  and  show  other  symptoms  of 
mental  confusion  and  incoherence.  They  also  experience  hallucina- 
tions affecting  the  senses.  The  excitement  sometimes  is  aggravated 
to  the  highest  possible  degree.  Fits  of  fury  and  delirium  lasting  for 
days,  combined  with  hallucinations,  mania  of  persecution,  etc.,  have 
frequently  been  observed.  The  delirious  attacks  may  also  occur 
intermittently.  A  lady,  for  instance,  jumped  up  in  a  delirious  fit, 
drank  water,  retired  to  her  bedroom,  and  there  had  another  spasm; 
afterward  she  had  no  recollection  of  the  incident.  During  the  stage 
of  excitement  in  another  woman  strongly  erotic  symptoms  were 
observed.  The  excitement  sometimes  alternates  with  depression, 
the  latter  in  the  form  of  pronounced  melancholia  with  delirium  of 
persecution,  or  of  the  type  of  profound  apathy  which  is  generally 
observed  after  excessive  excitement."     (Lewin.) 

"It  must  be  kept  in  mind  that  the  mucous  membranes,  owing  to 
their  great  vascularity,  absorb  the  alkaloid  more  rapidly  than  any 
other  tissues,  especially  when  the  former  are  inflamed.  Generally  it 
may  be  said  that  adults  can  tolerate  without  untoward  effects  up  to 
5  centigrams  of  a  i  or  2  per  cent,  solution.  In  dental  operations, 
however,  never  more  than  3  centigrams  should  be  injected. 

"  Cocain  intoxication  is  either  acute  or  chronic.  As  a  rule,  the  first 
symptoms  of  an  acute  cocain  intoxication  appear  within  ten  or  fifteen 
minutes  after  the  injection,  sometimes,  however,  not  before  half  an 
hour  or  three-quarters  of  an  hour  afterward.  These  symptoms  are 
the  following:  Precordial  depression,  closely  resembling  the  pain  in 
pulmonary  and  cardiac  oppression,  very  slight  and  rapid  pulse,  pallor 
of  the  face,  coldness  of  the  extremities,  abundant  perspiration,  high 
temperature  which  may  rise  to  40°  C,  irregular  respiration,  disturbance 


38  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

of  the  digestive  tract  in  the  form  of  biHous  vomiting,  sometimes  asso- 
ciated with  diarrhea,  diminished  urination  and  anuria,  which  in  some 
cases  was  observed  from  twenty-four  to  forty-eight  hours  after  injec- 
tion. The  psychic  disturbances  are  of  a  most  pronounced  character, 
and  manifest  themselves  in  the  form  of  excitement  or  garrulousness; 
sometimes  the  patient  sheds  tears,  or  exhibits  great  anger  or  fury! 
The  tactile  sense  is  impaired  especially  in  the  hands,  a  pricking  sensa- 
tion sometimes  being  noticed.  Cases  of  cramps,  of  symptomatic  cocain 
epilepsy,  have  been  observed,  followed  by  a  condition  of  motor  and 
sensory  paralysis  lasting  several  days.  Hysterical  attacks  have  also 
been  noted.  Cases  of  death  due  to  cocain  intoxication  have  occurred 
suddenly,  in  some  cases  two  minutes  after  the  employment  of  this 
alkaloid,  in  others  after  from  half  an  hour  to  five  hours.  While  the 
untoward  after-effects  are  not  often  fatal,  nevertheless  the  disagreeable 
secondary  symptoms  last  several  hours,  sometimes  several  days.  Post- 
mortem examinations  have  revealed  acute  congestion  of  the  lungs. 
Sometimes  numerous  small  infarcts,  also  edema  of  the  lungs,  inflam- 
mation of  the  cardiac  muscle  and  the  dura  mater,  have  been  observed, 
although  the  last  symptom  is  not  quite  certain."    (Brouardel.) 

In  a  long  series  of  carefully  conducted  experiments  Sikenberg^  has 
proved,  contrary  to  recent  teachings,  that  adrenalin  injected  simul- 
taneously with  or  after  cocain  does  not  reduce  the  toxic  effect  of  the 
latter.  Equal  doses  of  cocain  with  or  without  adrenalin  had  the  same 
effect,  the  lethal  dose  also  being  the  same.  The  effect  of  cocain  is  by 
no  means  intensified  by  the  addition  of  adrenalin,  and  the  same  quantity 
of  cocain  is  required  whether  adrenalin  is  added  or  not. 

The  limit  of  concentration  of  a  non-toxic  cocain  solution  cannot  be 
accurately  determined.  Cases  have  been  observed  in  which  more  than 
2  grams  of  cocain  were  tolerated  without  serious  sequelae,  while  very  low 
doses  of  I  cgm.  have  proved  fatal.  In  regard  to  toxicity,  it  is  important 
whether  strong  or  weak  doses  of  solution  are  employed,  also  whether 
the  drug  is  applied  to  the  mucosa  or  subcutaneously.  But  even  in 
subcutaneous   injection    the    alkaloid    perchance   may  enter  a  vessel 

'Archiv  f.  klinische  Chirurgie,  vol.  Ixxvii,  No.  2. 


AGENTS  FOR  LOCAL  ANESTLLESIA  39 

directly  and  get  into  the  circulation,  so  that  a  large  quantity  of  the 
poison  is  conveyed  to  the  brain  in  a  relatively  short  time.  The  absorp- 
tion of  the  solution  takes  place  much  more  rapidly  in  highly  vascular 
tissue,  such  as  the  oral  mucosa,  the  periosteum,  etc.  Cases  of  cocain 
intoxication  after  minimal  doses  must  be  attributed  to  idiosyncrasies. 

Cocain  is  a  pronounced  protoplasmic  poison.  It  immediately  retards 
the  ameboid  movements  of  certain  cells,  and  inhibits  diapedesis  of  the 
leukocytes.  Cocain  furthermore  is  a  specific  toxin  for  the  nerves, 
kidney,  and  heart;  diseases  of  these  organs,  therefore,  constitute  a 
contra-indication  to  this  drug.  Cocain  is  also  contra-indicated  in 
anemia,  chlorosis,  neurasthenia,  nephritis,  heart  disease,  physical 
debility  of  old  age  and  convalescence. 

It  was  only  natural  that  after  these  numerous  unfavorable  expe- 
riences with  cocain  and  its  solutions  the  writer  joined  such  investigators 
of  note  as  Braun  and  others  in  a  thorough  examination  of  the  substi- 
tutes for  cocain.  Of  the  cocain  mixtures  which  are  still  in  use,  eusemin, 
for  instance,  continues  to  enjoy  great  popularity.  In  a  prospectus 
eusemin  is  called  the  "ideal  local  anesthetic,  first,  because  of  its  ster- 
ility; second,  because  of  its  non-toxicity;  third,  because  of  its  effect 
as  proved  by  experiment  and  practice."  Regarding  the  second  point 
we  must  protest,  for  at  present  there  exists  no  entirely  non-toxic 
local  anesthetic,  least  of  all  should  any  solution  that  contains  cocain 
be  represented  as  non-toxic. 

Substitutes  for  Cocain. — After  an  experience  with  injection  anesthesia 
extending  over  ten  years,  we  feel  justified  in  making  a  statement  which 
characterizes  the  present  status  of  the  question  of  solutions.  Cocain, 
even  in  minimal  doses,  as  Biberfeld,  Lewin,  Dorn,  and  Ritter  have  con- 
firmed, can  have  toxic  secondary  effects,  and  eusemin  is  no  exception 
to  this  rule,  as  we  have  ascertained  by  experiment.  Like  Lewin  we 
must  assume  that  "  the  after-effect  of  cocain  anesthesia  does  not 
depend  upon  the  strength  of  the  dose  applied,"  but  that  the  patient's 
physical  and  psychic  condition  plays  also  an  important  role.  This 
latter  factor  may  be  so  preeminent  that  even  novocain,  in  harmless 
solution,  although  being  seven  times  less  toxic,  may  produce  toxic 
symptoms,  as  has  been  proved  by  several  reported  cases. 


40  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

That  novocain,  on  the  other  hand,  is  a  complete  substitute  for 
cocain  has  already  been  affirmed  by  Braun.  We  can  but  fully  endorse 
his  excellent  discussion  of  this  subject  after  having  employed  novocain 
to  the  fullest  extent  in  dental  practice.  We  do  not  hesitate  to  claim 
that  the  cocain  preparations  must  be  banished  from  injection  anes- 
thesia, and  novocain  must  be  adopted,  being  at  present  the  most , 
suitable  anesthetic.  Port,  for  instance,  in  over  300  injections  of  a  i 
per  cent,  novocain  solution,  has  observed  not  one  single  case  of  intoxi- 
cation, while  he  observed  notable  intoxications  in  an  equal  number  of 
control  injections  of  cocain,  among  these  being  one  serious  case. 

In  view  of  the  glaring  advertisements  of  various  anesthetics  which  are 
shrouded  in  more  or  less  mystery,  it  is  about  time  for  us  to  emancipate 
ourselves  from  the  manufacturers'  tutelage,  and  to  go  our  own  way, 
the  way  clearly  shown  us  through  the  unselfishness  of  our  investigators. 
When  coupled  with  a  perfect  knowledge  of  the  technique  of  injection, 
the  novocain  solution  will  never  be  found  wanting.  Most  cases  of 
failure  are  undoubtedly  due  to  a  lack  of  technical  skill,  according  to 
the  free  confessions  of  many  dentists  who  have  learned  or  practised 
local  anesthesia  in  our  clinic.  For  this  reason  an  elaborate  description 
of  the  technique  of  injection  is  offered  in  this  volume,  as  this  technique, 
taking  it  all  in  all,  is  indeed  much  more  difficult  than  it  may  appear  at 
first  glance. 

Novocain,  as  has  been  stated,  is  the  prince  of  substitutes.  Owing  to 
its  advantages,  it  is  being  more  and  more  generally  introduced  in  den- 
tistry after  having  already  found  its  place  in  surgery,  and  it  seems  to 
be  destined  to  supplant  cocain  entirely.  Basing  our  remarks  upon 
an  extensive  experience  with  anesthesia  by  novocain  solution,  we  shall 
therefore  chiefly  speak  of  that  preparation,  referring  to  cocain  and  its 
application  by  way  of  comparison  only. 


NOVOCAIN   AND   ITS   SOLUTIONS 

For  the  selection  of  an  anesthetic,  the  following  principles  have  been 
laid  down  by  Braun: 


NOVOCAIN  AND  ITS  SOLUTIONS  41 

1.  The  locally  anesthetizing  effect  of  the  drug  must  be  less  toxic 
than  that  of  cocain. 

2.  The  drug  must  not  cause  any  tissue  lesions. 

3.  It  must  be  soluble  in  water,  and  its  solutions  must  be  sterilizable. 

4.  It  must  allow  of  combination  with  suprarenal  preparations. 
Novocain. — Novocain  fulfils  these  requirements.     It  was  discovered 

by  Einhorn  in  1905.  It  is  a  white  powder,  readily  soluble  in  water 
(i  to  i).  The  salt  crystallizes  in  alcohol  in  form  of  small  needles 
which  melt  at  156°  C.  It  dissolves  in  the  proportion  of  I  to  i  in 
water,  forming  a  neutrally  reacting  liquid.  In  cold  alcohol  it  is 
soluble  at  the  ratio  of  i  to  30.  The  solutions  can  be  heated  up  to 
120°  C.  without  undergoing  decomposition.  After  suprarenal  extract 
has  been  added  to  a  novocain  solution,  the  mixture  should  not  be 
boiled  at  all,  or  for  a  very  short  time  only,  as  the  active  principle  of 
suprarenin  loses  its  effect  by  continued  boiling. 

Novocain  has  the  same  action  on  the  peripheral  sensory  nerves  as 
cocain.  A  1.5  per  cent,  solution  is  fully  sufficient  to  anesthetize 
within  ten  minutes  even  large  nerve  trunks  such  as  the  great  sciatic 
nerve. 

General  Effects  after  Absorption. — The  general  effects  after  the 
absorption  of  novocain  are  hardly  noticeable,  neither  circulation  nor 
respiration  being  influenced.  The  heart  action  is  not  affected.  From 
0.15  to  0.2  gram,  when  injected  subcutaneously  in  rabbits,  produce 
hardly  any  change  in  the  tracings  of  blood  pressure  and  respiration  as 
registered  by  the  kymograph.  Novocain  does  not  produce  mydriasis, 
disturbances  in  accommodation,  or  increase  in  intra-ocular  pressure. 
The  low  toxicity  of  novocain  can  easily  be  demonstrated  by  comparing 
the  lethal  dose  of  novocain  with  those  of  cocain  and  stovain  per  each 
kilogram  of  body  weight  in  different  animals. 

The  comparative  lethal  doses  of  these  drugs  when  injected  subcu- 
taneously are  per  kilogram  body  weight:  In  rabbits,  novocain,  from 
0.35  to  0.4  gram;  cocain,  from  0.05  to  o.i  gram;  in  dogs,  novocain, 
from  0.25  gram  (not  yet  lethal);  cocain,  from  0.05  to  0.07  gram.  The 
minimal  lethal  dose  in  rabbits  per  kilogram  body  weight  is  0.73  gram 
of  novocain  when  injected  subcutaneously  in  a  10  per  cent,  solution. 


42  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

Effects  of  Novocain. — Novocain  solutions  are  absolutely  non-irritant. 
Even  if  they  are  introduced  into  fresh  wounds  in  20  per  cent,  solutions, 
or  in  concentrated  powder  form,  not  only  no  symptoms  whatever  are 
observed  in  the  areas  of  application,  but  the  inflammatory  process  is 
even  favorably  influenced,  as  we  have  been  able  to  demonstrate.  The 
solutions  can  be  boiled  any  number  of  times  without  being  affected. 
The  toxic  effect  of  novocain  is  relatively  light.  In  very  high  doses 
tonicoclonic  spasms,  together  with  opisthotonos,  great  agitation, 
accelerated  and  shallow  respiration,  are  noted.  The  maximal  dose 
for  subcutaneous  injection  is  0.75  gram.  Novocain  is  seven  times 
less  toxic  than  cocain,  and  three  times  less  toxic  than  the  other  sub- 
stitutes thereof. 

Novocain  possesses  a  short  vasodilator  effect,  but  otherwise  it 
fully  equals  cocain  in  its  anesthetizing  power.  The  unfavorable 
vasodilator  action  is  eminently  counteracted  by  combination  with 
some  suprarenal  extract;  in  fact,  the  anesthetizing  power  of  novocain 
is  considerably  enhanced  thereby. 

Consequently,  as  Braun  has  openly  declared,  novocain  is  "an  ideal 
anesthetic  which  can  not  only  supplant  cocain  in  every  case,  but 
considerably  enhances  the  safety  of  local  anesthesia,  owing  to  the 
possibility  of  safely  injecting  much  greater  quantities  of  a  strongly 
active  anesthetizing  solution." 

Opinions  Regarding  Novocain. — "We  must  emphasize  that  our 
experiences  fully  coincide  with  those  of  Braun,  Hainecke,  and  Lawen. 
The  results  of  255  observations  have  proved  that  novocain  is  a  non- 
irritant,  quickly  and  intensely  active  local  anesthetic,  which  has  pro- 
duced no  toxic  secondary  effects,  no  irritation  or  necrotic  symptoms. 
Novocain  does  not  impair  the  effect  of  suprarenin  in  the  least,  and 
can  be  well  sterilized.  We  have  arrived  at  the  conviction  that  novo- 
cain at  present  is  the  only  known  agent  fit  to  supplant  cocain  in 
surgery,  and  we  can  warmly  recommend  it  for  use  in  medical  practice, 
judging  from  our  clinical  experiences."     (Danielsen.) 

"A  resume  of  our  clinical  experiences  shows  that  novocain  repre- 
sents a  non-toxic  and  fully  efficient  substitute  for  cocain  for  the  pur- 
pose of  local  anesthesia  by  injection  in  the  tissues,  its  maximal  dose 


NOVOCAIN  AND  ITS  SOLUTIONS  43 

being  0.5  gram,  permitting  of  an  ideal  combination  with  suprarenin 
and  producing  absolutely  no  irritation."     (Liebl.) 

Novocain-Suprarenin. — "The  effect  of  suprarenin,  far  from  being 
impaired,  seems  to  be  enhanced  by  novocain,  as  I  have  noticed  from 
my  very  first  and  numerous  investigations.  The  anemia  is  much  more 
pronounced  than  if  pure  suprarenin  solution  or  cocain-suprarenin 
solution  with  the  same  admixture  of  suprarenin  is  employed.  In- 
dependently of  my  observation.  Dr.  Biberfeld  had  noted  the  same 
curious  fact.  In  the  combination  of  novocain  and  suprarenin,  conse- 
quently, correlations  of  the  two  agents  play  a  part  very  favorable 
for  local  anesthesia,  inasmuch  as  very  small  quantities  of  suprarenin 
are  needed  to  intensify  the  local  anesthetizing  action  of  novocain  to 
such  an  extent  as  is  peculiar  to  cocain-suprarenin  solutions.  The 
same  small  quantities  of  suprarenin  suffice  to  retard  the  absorption 
of  the  two  drugs,  thereby  rendering  their  action  purely  local  and 
limited  to  the  place  of  injection.  The  anesthetizing  power  of  these 
novocain  solutions  in  regard  to  intensity,  duration,  and  extension 
is  at  least  as  great  as  that  of  cocain  solutions.  All  the  operations 
described  in  my  book  can  equally  well  be  performed  with  these  as 
with  cocain  solutions."     (Braun.) 

Suprarenin. — Suprarenin  is  a  product  of  the  suprarenal  gland 
possessing  the  specific  property  of  contracting  the  walls  of  the 
capillaries  and  small  vessels  within  the  region  of  injection,  thus 
reducing  the  toxic  effect  of  the  anesthetic  injected  in  the  solution 
by  retarding  absorption,  and  at  the  same  time  producing  an  anemia 
in  the  area  of  injection  which  affords  an  unobstructed  field  for  opera- 
tion without  parenchymatous  hemorrhage.  The  suprarenal  prepara- 
tions in  former  years  were  secured  from  the  suprarenal  glands  of  sheep 
and  oxen.  Recently,  suprarenin  is  being  prepared  synthetically,  being 
much  purer,  less  toxic,  and  more  stable  than  the  organic  preparation. 

Suprarenin  is  a  grayish-white  powder,  slightly  soluble  in  water, 
readily  soluble  in  dilute  acids.  It  is  the  most  powerful  of  all  chemical 
substances  thus  far  known,  being  active  even  in  a  dilution  of  i  to 
100,000.  Its  toxicity  is  consequently  relatively  high.  More  than 
0.5  mg.  should  never  be  injected  in  one  dose.     The  toxic  symptoms 


44  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

consist  chiefly   in   palpitation   of   the   heart,    oppression,  and  difficult 
respiration. 

Suprarenin  has  no  anesthetizing  power,  but,  as  has  been  said,  pro- 
duces contraction  of  the  small  vessels  and  capillaries.  A  concentra- 
tion of  I  to  1000  seems  to  be  most  favorably  indicated  for  injection. 

Adrenalin,  a  suprarenal  preparation  of  English  origin,  is  mixed  with 
a  small  quantity  of  chloretone  in  order  to  render  the  solution  more 
stable,  which,  however,  has  been  disputed  by  B.  Miiller,  who  found  that 
chloretone  impairs  its  action. 

Stability  of  Suprarenin  Solution.  —  Synthetic  suprarenin  is  stable 
only  to  a  limited  degree  after  the  bottle  has  once  been  opened.  If 
preserved  in  a  cool  place  in  sealed  dark  bottles,  however,  it  seems  to 
keep  very  long.  In  a  test,  up  to  six  months  the  solution  remained 
absolutely  clear. 

For  injections,  a  slightly  acidulated  sodium  chlorid  solution  is  used 
as  a  base,  the  suprarenin  being  added  in  the  concentration  of  i  to  looo. 
Even  fractions  of  i  mg.  of  suprarenin  suffice  to  render  the  largest  field 
of  operation  anemic,  if  the  solution  is  introduced  in  liberal  quantity 
and  evenly  distributed  in  the  tissue,  i.  e.,  all  along  the  periphery  of 
the  area. 

In  small  cork-stoppered  bottles  suprarenin  solution  does  not  keep 
as  well  as  in  glass-stoppered  ones.  Dr.  Schonbeck,  of  Leipzig,  has 
found  that  the  disintegration  of  the  solution  is  due  to  the  sulphur 
compounds  contained  in  rubber,  and  has  suggested  that  in  the  future 
glass-stoppered  bottles  shall  be  employed  in  marketing  suprarenin. 
The  color  of  the  glass  is  to  be  dark  red,  to  avoid  any  untoward 
decomposition  which  is  caused  by  red  and  yellow  light  specially. 

If  synthetic  suprarenin  is  exposed  to  light  for  some  time,  the  clear 
solution  undergoes  a  reddish,  later  on  a  yellow,  discoloration.  As 
long  as  the  solution  is  red,  it  can  still  be  used.  It  is  generally  employed 
in  combination  with  hydrochloric  or  boracic  acid. 

Biberfeld  ascertained  that  synthetic  suprarenin  equals  the  natural 
product  also  clinically. 

Action  of  Suprarenin. — Suprarenin  is  sold  and  used  in  physiological 
salt  solution  with  a  small  addition  of  thymol.     If  applied  externally  upon 


NOVOCAIN  AND  ITS  SOLUTIONS  45 

the  mucous  tissue,  the  sokition  produces  anemia  within  from  one-half 
to  five  minutes;  if  appHeci  hypodermically,  in  from  fifteen  to  thirt}' 
seconds.  The  anemia  is  complete  as  soon  as  the  formerly  red 
mucous  tissue  has  assumed  a  pale  whitish  shade.  The  action  of  the 
solution  extends  only  in  a  radius  of  from  i  to  2  cm.  After  the  anemia 
has  disappeared,  at  first  in  every  case  dilatation  of  the  vessels  ensues, 
until  gradually  the  vascular  wall  returns  to  its  normal  condition. 

Toxicity  of  Suprarenin. — Suprarenin  is  a  drug  which  may  exhibit 
intensely  toxic  action,  if  introduced  in  excessive  quantity  and  concen- 
tration into  the  circulation.  The  toxicity  is  greatest  if  the  drug  is 
injected  intravenously,  viz.,  directly  into  the  blood.  According  to 
Batelli,  the  toxicity  is  forty  times  greater  when  injected  intravenously 
than  when  injected  subcutaneously.  Even  the  doses  employed  for 
dental  purposes  sometimes  produce  disagreeable  toxic  symptoms, 
such  as  palpitation  of  the  heart,  acceleration  of  pulse,  dizziness,  faint- 
ing, and  collapse,  especially  if  stale  solutions  are  employed.  For  this 
reason  the  smallest  possible  violet  bottles  of  solution  should  be  em- 
ployed which  must  be  used  up  within  two  weeks  at  the  longest.  Ready- 
mixed  solutions  combined  with  novocain  are  the  best,  and  should  be 
dispensed  in  small,  violet  ampoules  of  i  and  2  c.c. 

The  maximal  dose  of  suprarenin  may  be  said  to  be  10  drops  of  a 
I   to  1000  solution  of  synthetic  suprarenal  extract. 

The  size  of  the  drops  is  measured  by  a  standard  pipette.  Seidel 
justly  emphasizes  accuracy  in  size  of  the  drops,  after  having  shown 
that  3  c.c.  of  synthetic  suprarenin  furnished  36  drops  with  the  dropper, 
93  with  the  pipette,  and  45  with  the  original  bottle.  Organic  supra- 
renin differed  in  this  respect  from  the  synthetic  product;  here  the  same 
quantity  gave  34,  73,  and  25  drops  respectively.  It  is  also  important 
to  avoid  the  sudden  introduction  of  a  large  quantity  of  the  drug  into 
the  blood.  The  solution  of  1  to  1000  already  represents  a  high  per- 
centage, hence,  when  injected  with  the  anesthetizing  solution,  it  should 
be  used,  if  anything,  in  more  dilute  form. 

The  Standard  Pipette. — Dr.  Schonbeck  has  endeavored  to  design 
a  so-called  standard  pipette  most  suitable  for  practice.  He  made  the 
interesting    observation    that    all    the    standard    pipettes,  as    bought 


46  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

in  various  drug  stores,  furnished  drops  of  different  sizes,  conse- 
quently no  uniform  standard  pipette  exists.  We  have  figured  that 
I  c.c.  of  I  to  1000  synthetic  suprarenin  should  be  divided  into  32 
drops  in  order  to  insure  the  normal  dose  of  suprarenal  extract.  This 
requirement  is  fulfilled  by  Dr.  Schonbeck's  so-called  "Tested  Standard 
Pipette." 

No  Tissue  Lesions  from  Suprarenin. — A  fortunately  rarely  occur- 
ring danger  consists  in  postoperative  hemorrhage,  which  has  been 
observed  in  reaction  to  the  resulting  abnormal  vascular  contraction 
with  subsequent  hyperemia,  especially  after  tooth  extractions.  Supra- 
renin by  its  extremely  local  action  retards  the  process  of  local  circu- 
lation most  pronouncedly,  and,  in  some  cases,  may  endanger  the 
dental  pulp.  This  danger,  however,  does  not  seem  to  exist  with  the 
now  generally  adopted  dosage  of  our  injecting  solutions,  as  Euler  and 
Scheff  have  recently  proved  experimentally.  The  latter  found  that 
novocain-suprarenin  solutions  disturb  neither  the  vitality  of  the  teeth 
anesthetized  nor  that  of  the  approximating  teeth  in  any  way  whatever, 
"provided  the  perfect  vitality  of  the  pulp  before  application  of  the 
drug  has  been  established  beyond  all  doubt."      (Scheff.) 

Dosage  of  Suprarenin. — It  is  important  to  discriminate  in  the  appli- 
cation of  suprarenin,  especially  to  reduce  the  dose  in  children  and 
in  the  aged.  If  arteriosclerosis  is  present  or  suspected,  a  lesion  of  the 
rigid  vascular  wall  may  occur.  In  weakly,  anemic,  and  pregnant 
patients  the  minimal  dose  should  always  be  employed. 

If  all  these  conditions  are  observed,  no  disturbance  in  the  patient's 
health  is  to  be  expected  from  a  correct  application  of  suprarenal 
extract,  as  our  experience  in  several  thousand  clinical  and  private  cases 
has  shown,  especially  if,  instead  of  the  highly  toxic  cocain,  the  most 
efficient  substitute,  i.  e.,  novocain,  is  injected. 

The  Injecting  Solution. — The  injecting  solutions  of  novocain-supra- 
renin must  always  be  as  pure  as  possible,  and  must  contain  no  admix- 
tures which  may  enter  into  the  composition  of  these  drugs  during  the 
process  of  manufacture.  Toxic  secondary  effects  may  occur,  unless 
the  solution  has  been  sufficiently  protected  from  light  and  heat  and 
subsequent  premature  decomposition. 


NOVOCAIN  AND  ITS  SOLUTIONS  47 

The  good  quality  of  the  sohition  is  generally  evinced  by  its  behavior 
in  the  living  organism.  It  must  penetrate  the  tissue  cells  without 
producing  any  lesions  by  way  of  turgescence  or  contraction.  This 
property  of  a  solution  is  called  isotonia. 

Isotonia. — Every  body  cell  is  protected  against  the  tissue  juices  by 
a  semipermeable  membrane  which  regulates  the  interchange  of  the 
juices  between  the  cell  contents  and  the  cell  environment,  i.  e.,  main- 
tains metabolism.  If  the  same  conditions  of  solution  are  present 
within  and  without  the  cell,  if  the  amount  of  salt  in  the  fluid  is  uniform, 
then  isotonia,  equal  tension  is  present.  If,  however,  the  amount  of 
salt  is  greater  in  the  environment  of  the  cell,  then  there  is  a  tendency 
to  establishing  compensation.  Since,  however,  only  the  water,  not 
the  salts,  diffuses  through  the  plasmatic  membrane,  the  salts,  on  the 
other  hand,  have  the  tendency  to  attract  the  water  from  the  cells, 
and  the  water  by  leaving  the  cells  produces  a  contraction.  Again, 
if  the  environment  of  the  cell  is  poor  in  salts,  the  cell  is  distended. 
The  power  that  regulates  this  compensation  is  called  osmotic  pressure. 
Disturbances  are  due  to  difi^erence  in  concentration,  i.  e.,  difi^erences 
in  the  osmotic  pressure  on  either  side  of  the  membrane.  If,  then, 
a  solution  is  injected  which  does  not  conform  with  the  amount  of 
salts  in  the  tissue,  the  cells  are  either  contracted  or  distended.  The 
absorption  of  the  injected  solution  is  retarded  and  a  pathological 
condition  ensues,  often  assuming  the  form  of  edema.  Hypertonic 
(rich  in  salts)  and  hypotonic  (poor  in  salts)  solutions,  in  unfavorable 
cases,  may  produce  necrosis  of  the  tissue,  especially  when  containing 
highly  toxic  drugs  such  as  cocain. 

Non-isotonic  Preparations. —  Numerous  solutions  in  the  market, 
besides  containing  an  admixture  of  highly  toxic  drugs,  lack  sufficient 
neutrality;  in  other  words,  they  are  not  isotonic,  as  has  been  proved 
by  the  writer's  former  assistants,  Buente  and  Moral.  Hemolysis  of 
the  human  blood  corpuscles  was  produced  by  the  following  drugs: 
Bernatzik's  solution,  Wilson's  anesthetic,  Krause's  world  anesthetic, 
adralgin.  Winter's  anesthetique  local,  Bonnighausen's  local  anesthetic 
"corona,"  subcain  (which  induced  the  formation  of  methemoglobin), 
nalicin,  andolin,  udrenin,  Pohl's  a-c  subcutaneous  tablets,  phenyphrin 


48  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

(which  also  induced  the  formation  of  methemoglobin),  orthonal, 
Ritsert's  simplex  subcutin,  Witte's  local  anesthetic,  dolorant  (pro- 
ducing  incipient    hemolysis),    Schroder's   analgeticum,    and   dolantin. 

Novocain,  on  the  other  hand,  penetrates  the  tissue  cells,  the  red 
blood  corpuscles,  etc.,  without  producing  any  irritation;  it  in  nowise 
impairs  the  hemoglobin,  and  permeates  even  the  nerve  substance, 
so  that  its  full  anesthetizing  power  remains  unchecked  throughout. 

The  injected  fluid  enters  the  circulation  most  rapidly.  As  one 
circulation  is  completed  in  the  human  body  within  twenty-seven 
seconds,  the  injected  fluid  reaches  the  heart  and  the  central  nervous 
system  within  about  thirteen  seconds.  This  explains  the  extraor- 
dinarily rapid  action  of  injected  toxic  agents  upon  the  organism. 

Harmless  solutions,  such  as  the  novocain-suprarenin  solution  recom- 
mended, are  very  readily  excreted  by  the  urine  and  the  perspiration, 
so  that  untoward  effects  of  a  local  (edema)  or  general  nature  are  not 
to  be  anticipated. 

Besides  the  above-mentioned  conditions,  an  injecting  liquid  must 
fulfil  the  following  requirements: 

1.  The  solution  must  produce  no  lesions  in  the  blood  or  the  tissue 
cells. 

2.  It  must  not  alter  the  hemoglobin. 

3.  It  must  not  produce  any  turgescence  or  contraction  of  the  cells, 
or  hemolysis;  it  must  be  isotonic.     Its  freezing  point  must  be  about 

-0.55°  c. 

4.  It  must  contain  the  anesthetic  in  the  exactly  suitable  mean 
concentration. 

5.  It  must  not  react  acid. 

6.  It  must  be  free  from  non-essential  or  harmful  admixtures. 

7.  For  the  sake  of  preservation  it  must  contain  an  antiseptic  that 
is  easily  tolerated  by  the  tissues. 

Admixture  of  Thymol. — To  fulfil  the  seventh  requirement  we  have 
for  years  added  thymol  to  the  solution,  this  antiseptic  having  proved 
itself  specially  suitable  for  this  purpose.  If  we  consider  that  thymol, 
next  to  corrosive  sublimate,  possesses  the  greatest  bactericidal  power, 
that  it  inhibits,  for  instance,  the  anthrax  bacillus  in  a  dilution  of  i  to 


NOVOCAIN  AND  ITS  SOLUTIONS  49 

33,000;  if  we  further  consider  that  even  solutions  of  i  to  looo  are 
tolerated  by  the  organism  without  irritation,  its  application  is  specially 
favorably  indicated  in  this  field.  Since  thymol,  moreover,  in  the  dilu- 
tion recommended  favorably  influences  the  anesthetizing  power  of  the 
novocain  solution,  it  must  be  regarded  as  a  most  felicitous  agent. 

Of  the  several  favorable  properties  of  thymol,  two  deserve  special 
emphasis — (i)  its  energetic  antiseptic  and  antizymotic  power;  (2)  its 
anesthetizing  power. 

Antiseptic  Property  of  Thymol. — Referring  to  the  first  property, 
relatively  small  quantities  of  thymol  greatly  retard  the  putrefaction 
of  organic  substances  and  inhibit  the  progress  of  an  already  active 
process  of  putrefaction.  Husemann  observed  that  pieces  of  muscle, 
preserved  in  concentrated  aqueous  solution  of  thymol  in  the  open  air 
and  in  a  hot  place,  remained  free  from  putrefaction  for  about  six  weeks. 
In  a  dilution  of  i  to  2000,  thymol  prevents  the  development  of  bacteria, 
and  in  a  concentration  of  i  to  200  impairs  their  propagating  power, 
consequently  it  exhibits  an  antibacterial  power  second  only  to  that  of 
corrosive  sublimate. 

Other  Effects  of  Thymol. — If  applied  in  sufificient  quantity,  a  o.l 
per  cent,  thymol  solution  completely  inhibits  sugar  fermentation,  or, 
if  applied  in  small  quantity,  permits  it  to  go  on  to  a  minimal  degree 
only.  As  employed  in  man,  toxic  phenomena  cannot  appear,  since  the 
effects  sought  in  certain  cases  are  obtained  by  solutions  of  a  strength 
which  is  far  below  the  toxic  maximal  dose. 

Anesthesia  by  Thymol. — Referring  to  the  second  requirement,  Lewin 
has  proved  b}'  animal  experimentation  that  a  i  to  1000  aqueous 
solution  of  thymol,  if  applied  to  the  epidermis  of  a  frog,  is  able  to  pro- 
duce a  paralysis  of  the  peripheral  endings  of  the  sensory  nerves  of  the 
skin.  Thymol,  if  applied  in  suitable  strength,  more  or  less  cauterizes 
the  mucous  membrane  or  the  tissues  lying  close  to  the  mucous  mem- 
brane. This  cauterization,  which  does  not  involve  any  serious  tissue 
lesion,  produces  insensibility  in  the  frog's  skin  and,  after  more  pro- 
found penetration,  also  in  the  superficial  muscular  layer. 

To  dentists  thymol  has  long  been  known  as  an  anodyne  in  pulpitic 
pain,  and  has  been  generally  and  successfully  applied  in  dressings 
4 


50         MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

not  only  for  disinfection,  but  also  for  palliation  of  pain.  "The  anodyne 
effect  of  thymol,"  Miller  says,  "in  pain  due  to  the  pulp  has  long  been 
known."  Thymol  probably  reduces  the  temperature,  counteracts 
the  hyperemia  in  pulpitis,  and  acts  as  an  anesthetic. 

Thymol  as  an  Admixture  to  Novocain  Solution. — From  these  facts 
we  have  considered  it  expedient  to  add  thymol  to  the  novocain  solu- 
tion, which  per  se  is  not  antiseptic.  To  be  sure,  novocain  solutions, 
even  in  large  quantities,  after  having  been  sterilized  once,  can  be 
preserved  for  a  considerable  length  of  time,  perhaps  even  permanently, 
if  they  remain  well  stoppered — this  being  of  prime  importance — just 
as  many  other  solutions  do  not  undergo  chemical  decomposition  so 
long  as  they  remain  sterile.  One  of  the  great  disadvantages  of  cocain 
is  the  generally  acknowledged  fact  that  solutions  thereof,  despite 
conscientious  sterilization,  remain  stable  for  only  a  short  time,  i.  e., 
that  they  are  quickly  decomposed  and  lose  their  power,  even  if  kept 
hermetically  sealed  from  the  open  atmosphere.  If  novocain  solutions 
that  have  once  been  sterilized  are  drawn  off  a  large  quantity,  from  case 
to  case,  we  run  the  risk,  every  time  we  open  the  bottle,  of  infecting 
the  solution  with  bacilli  from  the  surrounding  air.  According  to  the 
nature  of  the  invading  specific  microorganisms,  processes  of  fermenta- 
tion and  putrefaction  may  be  set  up  in  the  solution,  impairing  or  de- 
stroying the  stability  and  power  of  the  solution.  In  order  to  prevent 
such  decomposition,  the  solution  ■  itself  should  possess  antiseptic 
properties.  Antiseptic  thymol  solutions  are  known  to  retain  their 
aseptic  or  sterile  character,  because  they  successfully  combat  and 
destroy  any  accidentally  invading  microorganisms.  The  suprarenin 
solution  also  contains  an  admixture  of  thymol. 

Reduction  of  Body  Temperature. — Another  advantageous  property 
of  thymol  should  be  mentioned,  i.  e.,  its  power  of  reducing  the  body 
temperature.  From  2  to  3  grams  of  thymol,  if  applied  internally, 
are  able  to  produce  in  healthy  persons,  as  well  as  in  fever  patients, 
a  reduction  in  temperature  of  2°  C.  This  effect  is  hardly  pronounced 
in  the  generally  applied  solution  (i  to  2000),  but  it  enters  into  con- 
sideration in  the  generally  favorable  action  of  the  thymolized  solution 
in  regard  to  absorption,  especially  in  hyperemic  tissue. 


NOVOCAIN  AND  ITS  SOLUTIONS  51 

Thus  it  appears  that  the  addition  of  thymol  imparts  to  the  novo- 
cain solution  several  important  properties,  which  are  of  advantage 
in  a  local  anesthetic,  i.  e.,  inherent  antiseptic  power  guaranteeing 
the  permanent  asepsis  of  the  solution,  increase  in  anesthetizing  power, 
and  finally,  easy  and  convenient  manipulation.  By  this  composition 
it  becomes  unnecessary  to  resterilize  solutions  which  have  been  stand- 
ing for  some  time.  Consequently  the  advantages  accruing  from  the 
addition  of  thymol  render  its  admixture  to  the  novocain  solution 
indispensable,  especially  if  large  quantities  of  solution  are  kept  in 
stock,  to  be  used  from  time  to  time.  But  even  in  small  quantities, 
which  are  dispensed  in  ampoules,  the  admixture  of  thymol  has  proved 
to  be  invaluable. 

Temperature  of  the  Solution. — The  temperature  of  the  solution 
should  correspond  as  nearly  as  possible  to  that  of  the  tissues.  The 
farther  we  deviate  from  this  optimum  temperature,  especially  on  a 
downward  scale,  the  more  it  is  likely  that  irritations  will  be  produced. 
Injections  of  very  cold  or  hot  (above  +55°  C.)  solutions  produce 
serious  tissue  lesions,  usually  followed  by  extremely  painful  infiltrations. 
The  latter  occur  also  when  the  solution  is  not  quite  sterile,  or  the- 
admixtures,  especially  the  suprarenin,  have  undergone  alteration  or 
decomposition. 

Ampoules. — For  the  convenience  of  practice  we  have  made  tests 
in  order  to  ascertain  how  long  novocain-thymol  solutions  with  supra- 
renin added  will  keep  in  small  dark  ampoules.  After  fifteen  months 
the  solution  was  still  as  clear  and  effective  as  on  the  day  when  it  was 
prepared.  For  this  reason  we  can  warmly  recommend  the  0.5  to  1.5 
per  cent,  normal  solution,  which  is  dispensed  with  suprarenin  added, 
ready  for  use,  in  ampoules  of  I  and  2  c.c,  and  which  we  have  fre- 
quently tested.  This  normal  solution  represents  the  purest  stock 
solution  of  this  preparation  known. 

Nature  and  Manipulation  of  the  Ampoules. — Efforts  are  being  made 
to  manufacture  a  more  suitable  glass  for  these  ampoules,  the  cus- 
tomary brown  glass  not  meeting  all  requirements.  The  color  of  the 
glass  is  to  be  dark  red,  for  the  exclusion  of  all  deleterious  light  rays, 
which  is  not  obtained  with  brown  glass.     The  glass,  moreover,  must  be 


52  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

entirely  free  from  alkalies,  this  requirement  being  also  lacking  in  the 
glass  usually  employed  in  the  manufacture  of  ampoules. 

The  ampoule  itself  must  be  kept  as  sterile  as  every  other  instrument 
used  in  injection.  The  full  ampoule  contains  a  sterile  solution,  yet  its 
outer  surface  is  by  no  means  sterile.  It  passes  through  many  hands, 
is  packed  in  cotton  simply,  and  should  therefore  not  be  used  without 
having  been  previously  sterilized.  The  operator  is  cautioned  not  to 
nick  the  neck  of  the  ampoule  with  a  file  in  order  to  make  it  break 
more  easily.  This  measure  invites  sepsis,  and  is  absolutely  unneces- 
sary, even  dangerous.  From  the  file  numerous  infectious  bacteria 
are  introduced  into  the  sterile  solution  after  the  neck  is  broken.  The 
ampoules  are  best  sterilized  by  carefully  washing  from  about  6  to  lO 
of  them  in  a  weak  solution  of  carbolic  acid  or  lysoform,  and  then  pre- 
serving them  in  a  glass  jar  of  dark  violet  color  containing  absolute 
alcohol.  When  needed,  an  ampoule  is  taken  from  the  alcohol  with 
sterile  pincers  and  laid  between  sterile  gauze  or  cotton,  the  neck  of 
the  ampoule  is  broken  in  the  gauze — an  easy  procedure — the  mouth 
of  the  ampoule  is  carefully  exposed,  and  the  contents  are  drawn  out 
with  a  syringe  that  has  previously  been  sterilized  by  boiling.  Dr. 
Schonbeck  has  made  interesting  experiments  to  ascertain  whether  in 
the  customary  process  of  opening  an  ampoule  with  the  beaks  of  nippers 
or  by  holding  it  in  a  clean  napkin,  the  sterile  solution  can  be  infected, 
and  to  what  degree.  In  these  tests  the  outer  surface  of  the  ampoule 
which  contained  the  sterile  solution  was  not  previously  sterilized. 
In  all  cases  the  solution  was  found  to  be  infected.  It  remained  sterile 
only  when  carefully  manipulated  after  the  above-indicated  method. 

Grades  of  Concentration  of  the  Solution. — The  ampoules  are  furnished 
in  four  strengths,  viz.,  solution  i,  the  weakest,  0.5  per  cent,  novocain 
with  but  one-half  of  the  customary  suprarenin  admixture,  i.  e.,  h  drop 
from  the  standard  pipette  in  i  c.c;  solution  2,  being  a  i  per  cent, 
novocain  solution  with  two-thirds  of  the  usual  suprarenin  admixture 
(2  drops  in  3  c.c);  and  the  1.5  normal  solution,  with  the  usual  supra- 
renin admixture  (i  drop  from  the  standard  pipette  in  i  c.c). 

Solution  4,  Producing  More  Pronounced  Anemia. — Besides  these  solu- 
tions, upon  repeated  requests  a  solution  4  has  recently  been  kept  in 


NOVOCAIN  AND  ITS  SOLUTIONS  53 

Stock,  containing  a  larger  dose  of  suprarenal  extract.  In  extended 
surgical  operations,  in  which  greater  anemia  is  desirable  for  the  sake 
of  easier  control  of  the  field  of  operation,  local  mucous  anesthesia  is 
induced  in  the  region  to  be  operated  upon.  For  this  purpose  solution  4 
is  employed,  which  consists  of  the  1.5  per  cent,  normal  solution  with  an 
admixture  of  more  suprarenin  (3  drops  of  i  to  1000  synthetic  supra- 
renin  in  2  c.c.  of  solution)  without  involving  greater  risk  of  intoxica- 
tion. This  risk  is  successfully  minimized  by  application  of  the  stasis 
bandage,  which  will  be  described  below. 

This  scale  of  novocain  dosage  as  described  is  fully  endorsed  by 
Bolten-Husum:  "The  opinion  that  different  medicaments  are  required 
in  different  cases  must  be  contradicted.  Not  a  different  medicament, 
but  a  different  concentration  must  be  selected.  The  widely  reticulated 
spongiose  tissues  in  children  require  a  weaker  concentration  than  do 
the  tissues  in  adults.  Dentinal  anesthesia,  extirpation  of  a  vital  pulp, 
tooth  extractions,  pericementitis,  etc.,  all  require  special  consideration 
in  regard  to  selection  of  the  concentration  and  quantity  of  novocain 
and  suprarenin  to  be  injected." 

Tablets  Contraindicated. — Tablets  cannot  be  recommended  owing 
to  the  inconvenience  of  dissolving  and  boiling  the  same  in  each  case; 
moreover,  great  care  is  necessary  in  order  to  keep  these  tablets  sterile. 
The  prepared  novocain-thymol  solution  in  ampoules  recommended 
above  permits  of  considerably  easier  manipulation,  and  its  absolute 
sterility  is  guaranteed. 

Sterility  of  Tablets. — Braun  has  bacteriologically  analyzed  the  novo- 
cain tablets  of  one  drug  firm,  and  has  found  them  always  sterile. 
Some  time  ago  Hofi^mann  reported  that  on  analyzing  tablets  from 
some  other  drug  firm  he  found  that  over  one-half  contained  bacteria. 
Professor  Riesel,  upon  Braun's  instigation,  analyzed  numerous  tablets, 
all  of  which  were  found  sterile.  Nevertheless,  there  is  a  possibility 
of  tablets  occasionally  containing  bacteria. 

It  was  a  matter  of  great  importance  to  find  an  effective  and 
reliable  method  of  sterilization  for  these  tablets,  and  Braun,  after 
renewed  experiments,  soon  arrived  at  a  practical  result.  He  recog- 
nized  that  the   source  of  the    contamination   of   suprarenin   solution 


54         MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

invariably  lies  in  traces  of  alkalies  which  are  found  in  these  solutions, 
and  are  due  partly  to  the  alkaline  glass,  partly  to  other  causes.  In  a 
non-alkaline  glass  which  has  been  previously  treated  with  hydro- 
chloric acid,  suprarenin  solutions  can  be  boiled  in  absolutely  non- 
alkaline  sodium  chlorid  solution  or  in  non-alkaline  distilled  water,  or 
sterilized  in  steam,  the  solution  retaining  its  color  and  its  full  power. 
These  precautions  not  being  feasible  in  an  average  dental  office,  the 
absolutely  accurate  work  of  a  chemical  laboratory  is  required.  In  our 
operating  rooms,  where  a  lot  of  soap  and  soda  are  used,  it  is  impossible 
to  entirely  prevent  alkaline  traces  from  getting  into  the  solutions' 
this  difficulty,  however,  can  easily  be  overcome  by  other  means. 

To  one  liter  of  the  physiological  salt  solution  to  be  used  in  dissolving 
the  tablets,  2  drops  of  dilute  hydrochloric  acid  are  added.  Solutions 
of  novocain-suprarenin  tablets  in  this  slightly  acidulated  salt  solution 
may  then  be  either  boiled  or  sterilized  in  steam  without  losing  any 
of  their  power.  The  greater  stability  of  this  solution  is  evident,  as 
no  red  discoloration  at  all  occurs,  or,  if  any,  only  after  prolonged 
standing. 

"No  physiological  effects  from  this  added  tinge  of  dilute  hydro- 
chloric acid  can  be  noted  after  injection,  especially  no  tissue  lesions. 
On  the  other  hand,  the  hydrochloric  acid  suffices  to  neutralize  the  alka- 
line traces  which  may  be  present  in  the  salt  solution  or  in  the  vessels 
employed,  and  which  invariably  remain  in  the  syringes  and  the  needles 
that  have  been  boiled  in  soda  solution,  even  if  these  instruments  have 
been  washed  in  water  or  sodium  chlorid  solution."      (Peukert.) 

In  operations  in  the  mouth  Braun  employs  in  25  c.c.  salt  solution 
one  tablet  containing  0.00016  borated  suprarenin  in  a  dilution  of 
I  to  150,000.  Of  this  0.5  per  cent,  novocain  solution  up  to  150  c.c, 
containing  0.00096  gram  suprarenin,  could  be  safely  injected,  viz., 
more  than  the  maximal  dose  of  0.5  mg. 

Ampoules  Preferable  to  Tablets. — For  dental  practice  the  tablets 
do  not  seem  as  suitable  as  the  always  efficient  and  sterile  ampoules. 
In  the  first  place,  the  preparation  of  the  solution  is  troublesome  and 
successful  only  if  carried  out  with  most  painstaking  accuracy.  In 
the  second  place,  no  tablets  Avith  suprarenin  admixture,  owing  to  the 


NOVOCAIN  AND  ITS  SOLUTIONS  55 

well-known  chemical  instability  of  suprarenin,  keep  for  any  length 
of  time,  consequently  the  action  of  the  solution  is  uncertain.  For 
these  reasons  we  prefer  the  ampoules  in  every  respect,  especially  since 
they  are  sold  in  the  various  concentrations  of  the  normal  solution, 
and  can  be  procured  fresh.  These  ampoules  in  our  experience  keep 
unaltered  and  sterile  for  over  three  months. 

Preparation  of  the  Solution. — The  injecting  solution  requires  most 
careful  sterilization.  Dr.  Schonbeck  boils  the  prepared  solution  for 
ten  minutes,  leaves  it  standing  in  an  aseptic  environment  for  twenty- 
four  hours,  and  boils  it  once  more  for  ten  minutes  on  the  second  or 
third  day,  in  order  to  surely  destroy  any  bacilli  that  might  have 
entered  in  the  meantime.  Experiments  have  shown  that  occasionally, 
although  rarel}',  after  one  single  sterilization  of  ten  minutes,  cocci 
were  present  in  the  solution,  although  it  had  been  hermetically  sealed 
in  the  ampoules.  Since  the  solution  is  being  repeatedly  sterilized  by 
heat,  the  contents  of  the  ampoules  remain  invariably  sterile,  as 
continued  bacteriological  control  tests  have  shown. 

Stability. — The  date  of  manufacture  of  the  solution  should  be 
marked  on  every  ampoule,  so  that  there  can  be  no  doubt  as  to  the  age 
of  the  solution.  It  can  then  be  kept  with  perfect  safety  in  the  manner 
indicated  up  to  four  months,  and  probably  longer.  Despite  the  ad- 
mixture of  suprarenin,  no  discoloration  occurs  after  several  months; 
the  permanent  sterility  of  the  solution  is  further  increased  by  the 
admixture  of  0.05  thymol  in  100  c.c.  of  solution. 

Composition. — The  1.5  per  cent,  normal  solution  consequently  is 
identical  in  composition  with  the  solution  which  we  had  indicated 
as  being  fully  efficient  and  stable  as  early  as  1906,  our  formula  being: 

Novocain 0.75 

Sod.  chlor .      . O.45 

Thymol 0.033 

Sterilized  distilled  water 50. 0 

which  is  equal  to  Buente  and  Moral's  solution  produced  b}"  the  physico- 
chemical  method.  Only  the  addition  of  sodium  chlorid  has  since  then 
been  more  accurately  determined  at  0.46,  following  more  recent 
investigations.     Since  the  admixture  of  th^•mol  does  not  in  the  least 


56         MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

impair  the  isotonia  of  the  solution,  or  in  the  concentration  of  0.033 
produces  any  hemolysis,  we  have  approximately  retained  the  original 
admixture  of  thymol  in  the  normal  solution  (0.025).  It  should  be 
emphasized  that  the  solution  in  its  present  concentration  serves  all 
purposes,  and  that  failures  in  its  use  are  to  be  attributed  to  neglect 
of  one  of  the   numerous  contributory   factors. 

Factors  Affecting  the  Successful  Administration  of  the  Injection. — 
Cases  of  failure  are  not  to  be  attributed  to  the  solution  only.  It  is 
well  known  that  a  great  many  factors,  all  differing  in  their  special 
effects,  contribute  to  a  complete  success  of  the  injection  To  mention 
only  the  chief  ones:  The  solution,  the  glass  container,  the  syringe,  the 
needle,  and  the  field  of  operation  should  be  most  carefully  cleansed  and 
sterilized.  The  time  of  waiting  for  beginning  the  operation  proper 
must  be  correctly  calculated  from  a  consideration  of  the  normal  and 
pathological  anatomy  of  the  field  of  operation;  and  last,  but  not  least, 
the  technique  in  each  case  must  be  carried  out  in  such  a  manner  as 
will  most  fully  guarantee  success  in  every  respect.  The  diversity  of 
opinions  concerning  injection  is  not  at  all  surprising,  since,  owing  to 
the  complicated  nature  of  this  procedure,  failure  to  comply  with  one 
minor  requirement  impairs  the  effect,  and  may  produce  partial  or  total 
failure,  which  is  then  usually  attributed  to  the  anesthetic  agent  or 
solutions  thereof. 

The  Normal  Solution. — The  normal  solution,  which  has  been  defi- 
nitely adopted  after  a  series  of  experiments  by  the  writer's  former 
assistants,  Buente  and  Moral,  is  composed  as  follows: 

Novocain 1.5 

Sod.  chlor o ,  92 

Thymol 0.025 

Distilled  water 100. o 

Bottles. — For  busy  hospital  clinics  the  use  of  ampoules  is  too  ex- 
pensive, so  that,  in  our  opinion,  it  is  advisable  to  prepare,  before 
consultation  hours,  a  large  quantity  of  solution  from  the  stock  solu- 
tion and  to  add  the  suprarenin.  We  are  using  large  bottles  containing 
50  c.c.  of  novocain  solution,  drawing  off  5  c.c.  for  each  case  with  the 
graduate,  and  adding  5  drops  of  synthetic  suprarenin  with  the  standard 


NOVOCAIN  AND  ITS  SOLUTIONS  57 

pipette  (see  Fig.  4,  No.  6).  In  this  way  each  injection  can  be  individually 
prepared  to  the  most  minute  detail;  a  smaller  amount  of  suprarenin, 
for  instance,  is  added  to  the  solution  in  patients  affected  with  heart 
disease,  or  in  children,  thus  effectually  avoiding  intoxication. 

So  far  the  solution  has  proved  its  ideal  action  in  numerous  and  most 
difficult  cases,  and  must  be  regarded  as  perfect  in  every  respect,  ful- 
filling all  scientific  requirements  theoretically  as  well  as  practically. 
The  osmotic  pressure  of  this  solution  is  identical  with  that  of  the 
tissues,  producing  no  hemolysis  of  the  red  blood  corpuscles  or  tissue 
lesions.  By  the  avoidance  of  all  tissue  lesions  and  by  careful  disin- 
fection of  the  point  of  injection  with  weak  tincture  of  iodin,  edemata 
which  used  to  occur  frequently  after  injection  have  been  done  away 
with  almost  entirely,  which  is  another  proof  of  the  superiority  of  the 
normal  solution  advocated.  In  adults  with  normal  constitution  the 
1.5  per  cent,  solution  guarantees  perfect  success.  The  same  is  to  be 
said  of  considerably  weaker  novocain  doses  in  weakly  individuals 
and  children.  In  such  cases  even  a  0.5  per  cent,  novocain-thymol 
solution  has  proved  efficient,  the  toxicity  of  this  solution  being  corre- 
spondingly smaller  than  that  of  the  1.5  per  cent,  solution.  One  of  the 
greatest  advantages  of  this  relatively  harmless  local  anesthetic  is  that 
even  the  weakest  patient  can  be  relieved  of  pain.  Although  the  1.5 
per  cent,  novocain  solution  is  quite  well  tolerated  by  patients  of  reduced 
resistive  power  without  untoward  effects,  it  is  important  to  know  that 
the  same  effect  can  be  produced  in  weakly  patients  by  a  much  weaker 
novocain  dose,  hence  the  dose  may  be  varied  according  to  the  physical 
condition  of  the  patient,  greatly  to  the  advantage  of  his  general 
health.  Individualization,  therefore,  which  in  general  medicine  is 
being  more  and  more  strongly  emphasized  in  regard  to  therapeutics, 
is  no  less  a  postulate  in  dental  local  anesthesia. 

Braun's  Latest  Experiences  with  Novocain  and  its  Solutions. — The 
most  enthusiastic  champion  of  novocain  solution,  Braun,^  of  Zwickau, 
published  last  j'ear  a  comprehensive  treatise  on  the  employment  of 
novocain    in    surgery.      From    this   work   it   appears,    beyond   doubt, 

•  Beitrage  zur  Klinischen  Chirurgie,  1910.  F.  Peukert,  Further  Contributions  to  the  Application 
of  Local  Anesthesia  and  Suprarenin  Anemia. 


58         MODERN  LOCAL  ANESTHETLCS  AND  THELR  APPLICATIONS 

that  novocain  is  most  extensively  used  in  major  surgery,  especially 
in  small  doses,  viz.,  0.5  per  cent,  and  i  per  cent,  solutions. 

Braun  has  indicated  four  different  solutions,  the  weakest  being 
0.25  per  cent.,  the  strongest,  2  per  cent,  novocain.  Solutions  i 
(0.25  per  cent.)  and  2  (0.5  per  cent.)  are  employed  when  thick 
layers  and  extensive  areas  of  tissue  are  to  be  infiltrated.  Solutions 
3  (i  per  cent.)  and  4  (2  per  cent.),  which  contain  correspondingly 
more  suprarenin,  serve  for  conductive  anesthesia  proper.  Braun, 
for  the  sake  of  simplicity,  employs  as  few  anesthetizing  solutions  as 
possible,  and  preferably  only  one  form  of  tablets.  He  also  endeavors 
to  restrict  the  use  of  the  high  per  cent,  solutions  (3  and  4)  as  much 
as  possible.  "We  have  generally  substituted  the  I  per  cent,  solution 
for  the  2  per  cent,  solution,  injecting  a  little  more  of  the  former  than 
we  employed  originally."  Hence,  Braun  uses  in  the  main  only  two, 
namely,  the  0.5  per  cent,  and  the  i  per  cent,  novocain  solutions.  "The 
I  per  cent,  novocain  solution  suffices  for  tooth  extractions,  also  without 
exception  for  the  conductive  blocking  of  large  nerve  trunks." 

Application  of  Local  Anesthesia  in  Surgery. — The  wide  adoption 
of  local  anesthesia  in  surgery,  promoted  by  a  suitable  technique  of 
injection,  is  characterized  by  the  following  passages  in  Braun's  report: 

"Of  10  complicated  cases  of  fracture  of  the  skull  two  were  operated 
upon  under  local  anesthesia;  also  two  skull  trepanations  in  abscess  of 
the  brain,  /'.  e.,  suspected  abscess,  and  in  one  case  removal  of  a  bullet 
from  the  brain,  were  performed  under  local  anesthesia.  Peripheral 
injection  of  the  field  of  operation  with  0.5  per  cent,  novocain-suprarenin 
solution  is  a  superior  means  of  reducing  hemorrhage  in  cranial  opera- 
tions. It  supersedes  all  other  aids  recommended  for  this  purpose,, 
is  much  more  effective,  and  permits  of  the  performance  of  cranial 
and  cerebral  operations  with  a  minimal  hemorrhage  and  anesthesia. 
All  these  advantages  cannot  be  underestimated,  nor  can  they  be 
attained  by  any  other  similar  procedure. 

"One  operation  which  we  now  perform  exclusively  under  local  anes- 
thesia is  that  for  suppuration  in  the  frontal  and  the  ethmoidal  sinuses. 
All  operations  of  the  frontal  sinus  can  be  thus  performed,  the  chiselling- 
away  of  the  entire  anterior  and  inferior  walls,  Kilian's  radical  operation. 


NOVOCAIN  AND  ITS  SOLUTIONS  59 

Earth's  operation,  opening  into  the  ethmoidal  sinuses,  probably  also 
into  the  sphenoidal  sinuses.  The  field  of  operation  is  completely 
anesthetized  and  so  anemic  that  the  operation  can  be  carried  out 
much  more  easily,  neatly,  and  rapidly  than  under  general  anesthesia. 

"Braun  prefers  local  anesthesia  even  in  resection  of  the  maxilla, 
as  by  the  introduction  of  suprarenin  the  intensity  and  duration  of  the 
anesthesia  are  sufficiently  guaranteed.  Moreover,  by  inducing  scopo- 
lamin  slumber,  we  are  enabled  to  do  away  with  the  unfavorable 
psychic  impression  of  the  operation  upon  the  partially  anesthetized 
patient. 

"The  anesthetization  of  the  superior  maxillary  nerve  in  the  spheno- 
maxillary fossa  has  been  accomplished  in  5  cases  successfully  and  with- 
out any  difficulty.  The  point  of  injection  lies  closely  posterior  to  the 
inferior  palpable  process  of  the  malar  bone,  whence  the  needle  is 
advanced  inwardly  and  upwardly,  its  point  immediately  back  of  the 
zygoma  reaching  the  maxillary  tuberosity.  Gently  palpating  along  the 
surface  of  the  latter,  the  needle  easily  advances,  and,  in  a  depth  of  from 
5  to  6  cm.,  meets  the  superior  maxillary  nerve  in  the  sphenomaxillary 
fossa.  The  patient  immediately  feels  pain  radiating  into  the  maxilla. 
The  syringe  is  then  attached  to  the  needle,  and  under  slight  backward 
and  forward  motion  of  the  needle  from  5  to  10  c.c.  of  a  I  per  cent, 
novocain  solution  are  injected.  The  injection  can  be  executed  easily 
and  safely.  Anesthesia  in  the  whole  area  of  the  superior  maxillary 
nerve  ensued  in  all  cases  almost  immediately  after  the  injection." 

Of  7  cases  of  resection  of  the  maxilla  2  had  to  be  treated  under 
general  anesthesia  owing  to  excessive  extension  of  the  tumor.  The 
other  5  were  operated  upon  under  local  anesthesia. 

"The  course  of  operation  under  local  anesthesia  is  quite  different 
from  the  usual.  No  interruptions  of  the  operation  as  needed  for  the 
continuance  of  general  anesthesia  are  required,  and  the  operation  can 
be  completed  in  a  minimum  of  time.  Owing  to  the  anemia  from  the 
suprarenin  the  continual  inundation  of  the  field  of  operation  with  blood 
is  avoided,  and  the  few  bleeding  vessels  can  be  quickly  and  conveniently 
compressed.  The  non-obstruction  of  the  oral  area  permits  of  operating 
accurately  and  neatly.      If  blood  flows  into  the  pharynx,  the  patient  is 


60         MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

always  able  to  prevent  its  aspiration,  all  reflexes  being  maintained. 
The  patients'  condition  after  the  operation  is  most  favorable;  they 
leave  the  operating  table  perfectly  well  and  rarely  have  to  be  put  to 
bed.  Owing  to  the  effect  of  scopolamin,  they  frequently  have  little 
or  no  reminiscence  of  the  operation.  It  is  not  saying  too  much  that, 
owing  to  the  employment  of  local  anesthesia  and  suprarenin  anemia, 
resection  of  the  maxilla  has  lost  all  its  terrors.  Local  anesthesia  in 
this  operation  is  not  equivalent  to  general  anesthesia,  but  far  superior." 

In  the  tongue  also  major  operations  can  be  performed  under  local 
anesthesia.  Braun  undertook  even  more  complicated  operations,  per- 
forming extensive  extirpations  of  glands,  temporary  separation  of  the 
maxillae,  and  removal  of  maxillary  fragments  under  local  anesthesia. 
The  anemia  produced  greatly  facilitates  the  technical  execution.  He 
also  mentions  3  cases  of  carcinoma  of  the  tongue  and  the  floor  of  the 
oral  cavity  which  were  operated  upon  under  local  anesthesia. 

Advantages  of  Local  Anesthesia  in  Surgery. — "Local  anesthesia 
has  been  charged  with  being  too  complicated  and  thus  unsuitable 
for  extensive  clinical  practice,  which,  however,  is  not  true.  Schleich's 
infiltration  anesthesia,  to  be  sure,  was  complicated,  since  the  scalpel 
had  to  aid  the  syringe  continually,  and  even  then  no  satisfactory 
anesthesia  could  be  obtained.  The  patients  became  restless,  began  to 
complain,  and  often  general  anesthesia  had  to  be  resorted  to  after  all. 
The  operations  were  thereby  prolonged  unduly,  and  the  patient  as 
well  as  the  operator  received  most  disagreeable  impressions.  Not  so 
with  the  modern  method  of  local  anesthesia.  All  injections  are  made 
before  the  operation,  if  desirable  even  before  sterilizing  the  field  of 
operation.  The  injections  require  no  longer,  usually  a  much  shorter 
time  than  the  production  of  general  anesthesia.  If  several  operations 
have  to  be  made  in  succession,  the  assistant  can  make  the  injections 
in  a  separate  room  shortly  before  termination  of  the  preceding  opera- 
tion, so  that  no  time  whatever  is  lost.  If  the  correct  technique  is 
employed,  there  is  no  need  for  long  waiting.  After  completion  of  the 
injection,  we  immediately  prepare  ourselves  for  the  operation,  and 
preparation  requires  but  a  short  time  if  sterile  gloves  and  long-sleeved 
sterile  operating  coats  are  worn.     In  the  meantime  the  field  of  opera- 


INSTRUMENTARIUM  61 

tion  is  sterilized.  If  the  operation  is  begun  after  from  eight  to  ten 
minutes,  complete  anesthesia  will  have  been  established.  In  large 
surgical  institutions  the  saving  in  assistants  and  anesthetists  is  a 
considerable  one. 

"Since  the  patients  retain  their  consciousness,  and  a  continual  con- 
versation between  operator  and  patient  can  be  carried  on,  disturbing 
movements  of  defence,  if  the  anesthesia  is  temporarily  superficial, 
can  be  prevented,  and  the  patient  is  able  to  cooperate  in  making 
minor  changes  in  position,  etc.,  without  the  assistance  of  a  third 
person."     (Peukert.) 

This  most  favorable  report  speaks  so  eloquently  for  the  employment 
of  local  anesthesia  in  major  surgery  that  it  is  surprising  that  dentistry, 
being  a  specialty  of  minor  surgery,  has  not  yet  definitely  and  uncon- 
ditionally adopted  these  views.  As  Braun  expresses  it  in  a  personal 
letter:  ''In  surgery  cocain  has  become  obsolete  since  the  introduction 
of  novocain,  and  is  no  longer  used.  The  old  drugs  [cocain]  are,  of 
course,  still  being  sold  by  supply  houses  as  long  as  there  is  a  demand 
for  them."  This  proves  that  our  demand  to  substitute  novocain  for 
cocain  is  fully  justified  and  requires  no  further  arguments. 

On  the  other  hand,  the  investigations  of  Braun  show  that  a  con- 
siderable reduction  in  the  concentration  of  the  novocain  solution  is 
indicated  for  local  anesthesia.  In  the  normal  solutions  Nos.  i,  2,  and  3, 
as  above  recommended,  this  requirement  has  been  taken  into  account. 
Just  as  Braun  has  produced  remarkable  results  with  a  i  per  cent. 
novocain  solution,  so  do  solutions  ranging  from  0.5  to  1.5  per  cent, 
when  adapted  to  individual  cases,  guarantee  full  success  in  dental 
practice,  depending,  of  course,  to  a  great  extent,  upon  the  technique 
of  injection  and  the  cautionary  measures  employed. 


INSTRUMENTARIUM 

For  injection  anesthesia  such  an  instrumentarium  must  be  selected 
as  will  fully  comply  with  all  modern  rules  of  asepsis,  and  can  be 
subjected  to  any  form  of  sterilization,  especially  boiling. 


62  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 


The  Injection  Syringe. — These  requirements  have  always  involved 
the  greatest  difficulties  in   this  most   important  instrument,   because 

Fig.  I 


Injection  syringe  of  glass  and  metal,  designed  by  Dr.  Guido  Fischer.     (For  explanation  of  lettering 

see  Fig.  2.) 


INSTR  UMEN  TARIUM 


63 


leather-piston  syringes,  the  most  tightly  closing,  must  not  be  exposed 
to  steam,  while  the  glass-and-metal,  all-glass,  or  all-metal  syringes 
never  possess  an  hermetically  fitting  piston.     After  examining  a  great 


i  \ 


m 


XceiUf  ill  shui-l  hub.  Xeedle  in  long  hah.  Needle  screwed  on  si/iiiifie 

{cross-sectlu,D. 


£  C 


Improved  needle.  Short  Lomi 

hub. 


D  D  E 

Bayoiti't-sliaped  Curved 

middle  pieces. 


Wrench. 


Needles,  hubs,  and  wrench  for  injection  syringe,  designed  by  Dr.  G.  Fischer.  At  the  left  is  a 
considerably  enlarged  reproduction  of  the  new  needle  showing  the  details  of  construction  as 
follows:  I,  the  hollow  needle,  either  of  seamless  steel,  pure  nickel,  gold  or  iridio-platinum; 
2,  body  of  soft  metal  for  firmly  tightening  the  needle  upon  the  orifice  of  the  syringe;  3,  conical 
shell  of  hard  metal,  open  below,  from  which  the  soft  metal  core  protrudes.  This  arrangement 
remedies  the  deficiencies  of  the  old  styles  of  needles  in  which  the  unprotected  soft  metal  cone 
could  not  stand  much  use,  became  flattened  easily,  and  jammed  in  the  hub  so  firmly  that  both  hub 
and  needle  had  to  be  replaced,  which  was  rather  expensive  if  gold  or  iridio-platinum  needles  were 
used.  The  new  needles  are  attached  to  the  syringe  absolutely  tightly  by  inserting  the  needle  in  one 
of  the  hubs  (B  or  C)  and  screwing  it  firmly  on  the  orifice  of  the  syringe.  In  order  to  enable  prac- 
titioners with  sensitive  fingers  easily  to  manipulate  the  hubs,  which  heretofore  were  milled,  the  hubs 
B  and  C,  also  the  middle  pieces  D  and  E,  are  made  with  hexagonal  coimections,  so  that  they  can  be 
conveniently  and  firmly  tightened  by  a  slight  turn  of  the  wrench.  No  force  should  be  used,  other- 
wise the  soft  metal  cone  of  the  needle  becomes  unnecessarily  worn. 


number  of  models,  we  have  finally,  with  the  assistance  of  Freienstein, 
of  Berlin,  designed  a  sj'ringe  which  seems  to  fulfil  all  the  necessary 
requirements  in  every  respect. 

This  syringe  is  made  of  glass  and  metal,  resembling  in  principle  the 


64 


MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 


Progress  syringe,  and  is  constructed  so  as  to  avoid  all  minute  furrows 
and  corners  which  catch  dirt  and  are  difficult  to  clean  (Fig.  i).  The 
entire  outer  surface  of  the  syringe  is  uniformly  round  and  smooth, 
and  the  hubs  A  to  E  are  tightened  with  a  wrench  (Fig.  2).  The  metal 
piston  is  made  accurately  and  fits  tightly  in  the  glass  barrel,  ending 
in  a  crutch-shaped  handle,  so  that  it  can  be  conveniently  laid  against, 
the  ball  of  the  thumb  and  firmly  braced  there.  This  handle,  being 
threaded  and  fastened  in  a  screw  socket,  can  easily  be  shortened  or 
lengthened.  To  produce  the  pressure  necessary  for  injection,  two  wing- 
like, strong,  and  milled  finger  rests  are  applied,  being  a  little  smaller 
in  the  i  c.c.  syringe  than  in  the  larger  size. 


1 


1 


Improved  injection  needles  for  dental  practice:  No,  i,  length,  42  mm.  with  long  point;  diameter, 
0.9  mm.;  No.  17,  a,  length,  23  mm.;  b,  length,  26  mm.;  c,  length,  42  mm.;  diameter,  0.47  mm.; 
No.  18,  length,  16  mm.;  diameter,  Q.42  mm. 

For  practical  reasons,  this  model  is  made  in  two  sizes,  the  one  syringe 
holding  I  c.c,  the  other  2  c.c.  On  the  glass  barrel  a  scale  is  etched 
for  gauging  the  contents.  After  some  time,  viz.,  after  from  three  to  six 
months  of  continual  use,  the  piston  wears  and  should  then  be  replaced, 
as  the  required  tightness  decreases.  It  is  best  always  to  keep  three  or 
four  syringes  of  both  sizes  in  stock. 

Hubs. — The  syringe  is  sold  with  various  smooth  hubs  (Figs,  i  and  2, 
B  and  E),  which  are  employed  according  to  the  place  of  injection.  The 
closing  cap  A  is  used  to  close  up  the  barrel  after  use. 


INSTRUMENTARIUM  65 

Needles. — For  our  purposes  the  needles  No.  17,  with  short  points 
(Fig.  3),  are  employed.  The  needles  Nos.  i  and  18  in  the  same  illus- 
tration are  suitable  for  special  purposes;  No.  i  (diameter  0.9  mm.) 
for  mandibular  anesthesia  as  preferred  by  Williger,  No.  18  for  periosteal 
injection,  where  a  specially  short  needle  is  desirable. 

The  three  needles  No.  17  have  a  diameter  of  0.47  mm.,  a  being 
23  mm.,  b,  26  mm.,  and  c,  42  mm.  long.  In  contradistinction  to  needle 
No.  I,  the  needles  Nos.  17  and  18  are  ground  with  blunt  ends,  which 
are  indispensable  in  anesthesia  of  the  bony  tissue  (Fig.  3).  Long- 
drawn-out  needle  points  are  not  suitable,  as  they  easily  get  stuck 
in  the  periosteum  and  bone,  break  or  bend,  and  cause  complications. 
Since,  however,  in  mandibular  anesthesia  the  needle  is  to  be  advanced 
along  the  bone,  we  prefer  needle  No.  17  to  No.  I,  especially  since 
the  orifice  of  the  latter  needle  may  cause  a  too  rapid  and  abundant 
discharge  of  the  fluid. 

The  needles  have  been  so  improved  by  Freienstein  that  they  can  be 
firmly  locked  in  the  hubs,  and  hermetical  closure  during  the  injection 
is  guaranteed  (Fig.  2,  No.  2).  The  cone  of  soft  metal  is  protected  by 
a  hard  metal  case  of  heavily  gilded  copper ;  it  is  open  below,  whereby, 
even  under  firm  pressure,  flattening  of  the  soft  metal  cone  and  stick- 
ing of  the  needle  in  the  hub  are  prevented,  also  the  exactly  central 
position  of  the  needle  is  insured,  preventing  all  possibility  of  leakage, 
all  of  which  constitutes  a  great  advantage  (Fig.  2,  left). 

Treatment  of  the  Needles. — Whenever  possible,  new  needles  should 
be  used,  since  steel  needles  that  have  been  used  and  have  not  been 
perfectly  dried  rust  readily  and  break  easily.  After  repeated  use  the 
needle  becomes  dull,  and  is  then  unfit  for  our  purposes.  Our  plan 
is  to  use  a  needle  for  one  day's  work  only,  and  then  discard  it.  After 
each  using,  the  needle  is  placed  in  a  bottle  containing  absolute  alcohol, 
the  bottle  is  shaken,  the  needle  removed,  and  the  needle  canal  vigor- 
ously blown  out  with  the  air  syringe;  a  wire  is  then  introduced,  and 
the  needle  laid  in  a  dry  test-tube  until  the  next  injection.  Before  inject- 
ing, the  needle  is  screwed  to  the  filled  barrel  and  sterilized  by  immersing 
for  one  minute  in  boiling  water. 
5 


66  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

Treatment  of  the  Syringe. — The  syringe  is  best  kept  in  a  tall  vessel 
filled  with  absolute  alcohol.  Alcohol  is  bactericidal,  does  not  attack 
the  metal  parts,  and  evaporates  as  soon  as  the  syringe  is  removed. 
After  use,  hot  water  is  drawn  into  the  barrel  several  times,  the  closing 
cap  A  is  screwed  on  the  ferrule  (Figs,  i  and  2),  the  syringe  is  dried 
carefully  and  preserved  in  absolute  alcohol  (Fig.  4,  No.  3).  In  order, 
to  preserve  the  alcohol  at  full  strength,  we  lay  on  the  bottom  of  the 
hermetically  closing  jar  with  ground-glass  cover  a  small  linen  bag 
(Fig.  4,  No.  3)  containing  annealed  copper  sulphate  in  white  powder 
form.  This  chemical  absorbs  the  water  introduced  into  the  alcohol 
from  the  atmosphere  and  the  syringe,  and  keeps  it  relatively  anhy- 
drous (about  99  per  cent.),  until  the  copper  sulphate  in  the  bag  has 
resumed  its  natural  blue  color. 

Ampoules. — If  ampoules  are  employed  (Fig.  4,  No.  10)  no  further 
instrumentarium  is  required.  In  a  sterile  napkin  the  neck  of  the 
previously  sterilized  ampoule  is  broken,  and  the  injecting  liquid  is 
drawn  into  the  syringe  through  the  mounted  needle.  Shortly  before 
this  the  needle  is  boiled  in  water  that  contains  no  soda,  thereby  ful- 
filling all  reasonable  requirements  of  asepsis.  Novocain  is  precipitated 
in  water  that  contains  soda,  therefore  the  water  used  in  boiling  the 
needle  must  be  pure. 

Preparation  of  the  Solution  for  Injecting. — Though  less  convenient, 
yet  more  suitable  if  larger  quantities  of  injecting  solution  are  required, 
is  the  method  of  adding  the  suprarenin  to  the  novocain  solution 
shortly  before  use.  In  Fig.  4,  Nos.  2  to  9,  we  have  assembled  the 
apparatus  required  for  this  purpose.  The  dark  rubber-stoppered 
bottle(No.  4),  which  holds  50  c.c,  contains  the  novocain-thymol  solution, 
the  small  suprarenin  bottle  (No.  5)  contains  5  c.c.  of  i  to  1000  synthetic 
suprarenin,  which  is  withdrawn  by  the  finely  pointed  standard  pipette 
(No.  6,  fastened  to  the  bottle).  Generally  the  novocain  solution  is 
mixed  in  a  long  and  narrow  graduate  (No.  8)  holding  5  c.c.  We 
prefer,  however,  a  short  and  wide  glass  (No.  7),  because  from  this  the 
solution  can  be  easily  withdrawn,  while  in  a  long  and  narrow  graduate 
only  the  long  needles  reach  deeply  enough,  and  the  graduate  has  to 
be  inclined  in  withdrawing  the  liquid.     After  mixing  the  solution  the 


INSTR  UMENTA  RI UM 


67 


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68 


MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 


graduate  is  closed  with  a  cotton  wad.  The  hubs  and  wrench  (No.  i) 
are  kept  in  a  glass  tray  filled  with  absolute  alcohol  (No.  9;  the  cover 
is  removed). 

Small  quantities  of  solution  are  mixed  in  the  small  glass  tray  (No.  2), 
which  holds  3  c.c.  With  the  exception  of  the  original  bottles  of 
novocain  and  suprarenin,  which  are  filled  under  aseptic  precautions,  ■ 
and  therefore  require  no  further  disinfection,  all  instruments  should 
be  sterilized  by  steam,  according  to  the  necessary  hygienic  require- 
ments. Freshly  mixed  open  solutions  should  be  used  up  as  fast  as 
possible.  After  a  short  time  (from  one  to  two  hours)  the  solution 
assumes  a  reddish  discoloration,  and  should  then  no  longer  be  used, 
even  though  it  be  still  effective.  A  liberal  use  of  fresh  solutions  is 
advisable,  as  economy  in  this  respect  or  in  the  use  of  needles  is  ill- 
advised. 

Fig.  5 


Stasis  bandage  applied  to  patient's  neck.     Diminishes  danger  of  intoxication  and  anemia  of   tlie 
brain,  and  retards  absorption. 


Stasis  Bandage. — Finally  a  very  practical  addition  to  the  instru- 
mentarium  should  be  mentioned,  i.  e.,  the  stasis  band  as  devised  by 
the  writer.  This  is  adjusted  by  means  of  a  number  of  eyelets,  and 
fitted  around  the  patient's  neck  tightly  enough  to  cause  the  face  to 
become  slightly  reddened  (Fig.  5) ;  deep  red  or  blue  coloration  must 


DISINFECTION  OF  THE   FIELD  OF  OPERATION  09 

be  avoided.  This  bandage  produces  stasis  of  the  carotid  arteries,  thus 
rendering  cerebral  anemia  less  likely  to  occur,  retaining  the  anesthetic 
in  the  desired  field  for  a  longer  period,  and  still  further  retarding 
absorption.  In  this  way  still  greater  certainty  of  success  is  guaran- 
teed, the  danger  of  intoxication  is  minimized,  and  fainting  spells  due 
to  cerebral  anemia  are  prevented  or  at  least  lessened.  The  hyperemia 
which  follows  stasis,  and  is  always  favorable,  seems  advantageous  for 
the  healing  process  of  wounds.  This  hyperemia  is  never  pronounced 
enough  to  produce  hemorrhage,  but  ranges  within  moderate  physio- 
logical limits.  For  the  formation  of  clot  in  the  wound,  the  hyperemia 
following  the  removal  of  the  bandage  is  of  incalculable  value,  prevent- 
ing, as  it  does,  disturbances  in  the  healing  process,  postoperative  pain, 
necrosis,  etc.,  which  often  follow  excessive  anemia.  Normal  circula- 
tion is  rapidly  reestablished.  So  far,  this  stasis  bandage  has  proved 
very  successful. 


DISINFECTION   OF  THE  FIELD   OF   OPERATION 

Disinfection  of  the  Mucosa. — Not  only  are  the  instruments  and  the 
operator's  hands  to  be  sterilized  before  injection  of  a  local  anesthetic, 
but  the  oral  mucosa,  which  is  always  infected,  must  also  be  most  thor- 
oughly and  carefully  sterilized.  Among  disinfectants,  iodin  occupies 
a  predominant  place.  Disinfection  with  iodin  (iodo-benzin)  plays 
an  important  part  in  modern  surgery,  hardly  any  incision  in  the 
epidermis  being  made  without  previous  swabbing  with  iodin.  This 
antiseptic  not  only  possesses  deep  penetrating  power,  but  also  pro- 
duces dryness  of  the  swabbed  area,  which  is  of  special  advantage  in 
the  oral  cavity. 

Effect  of  Iodin. — Tincture  of  iodin  (tincture  of  iodin  and  tincture 
of  aconite,  equal  parts),  according  to  Konig,  fulfils  the  requirements 
"which  are  considered  in  all  modern  efforts  at  disinfection  as  most 
essential,  7.  e.,  hardening  the  skin,  tanning  it,  as  it  were,  and  fixing 
the  bacteria  for  some  time  in  such  a  way  that  they  cannot  get  into 
the  wound.     That   iodin,    besides  these   properties,    retards   bacterial 


70  MODERN  LOCAL  ANESTHETICS  AND   THEIR  APPLICATIONS 

growth  is  well  known."  lodin  clings  for  a  long  time  to  the  tissue  to 
which  it  has  been  applied,  thus  insuring  deep  penetration.  In  a  dilution 
of  I  to  6000  iodin  impedes  bacterial  growth.  Lewy  justly  emphasizes 
that  the  tanning  of  the  mucosa  is  an  advantage  "facilitating  the  in- 
troduction of  the  needle  into  spongy  gums."  The  purely  superficial 
brown  coloration  of  the  place  of  injection  is  also  of  importance,  as  it 
very  clearly  marks  the  prepared  portion  of  the  skin. 

Application  of  Iodin. — The  painting  with  iodin  is  accomplished  not 
merely  by  applying  a  few  touches,  but  by  repeatedly  wiping  to  and  fro, 
in  order  to  combine  real  mechanical  cleansing  with  the  disinfection, 
and  to  effect  penetration.  The  filled  syringe  is  once  more  dipped  in 
boiling  water,  and  the  injection  then  made. 

Sterility  in  Injecting. — As  the  injection  generally  precedes  surgical 
intervention,  it  plays  a  part  in  the  subsequent  healing  of  the  wound. 
For  this  reason,  even  in  a  very  minute  injection,  full  attention  must 
be  paid  to  sterility,  as  untoward  sequelae  may  arise  from  neglect  of 
one  of  the  factors  involved.  Many  cases  of  edema  following  injections 
are  attributable  to  insufiicient  asepsis,  such  as  neglect  in  sterilizing 
the  hands,  the  instruments,  the  solution,  or  the  field  of  operation. 


PART    II 

INDICATIONS  FOR  LOCAL  ANESTHESIA 

DANGERS   OF  LOCAL  ANESTHESIA 

The  dangers  of  local  anesthesia  vary  according  to  the  method 
employed  and  the  care  observed  in  inducing  anesthesia.  With  cocain 
substitutes  these  dangers  are  considerably  less  than  with  cocain  itself. 
Whole  volumes  could  be  written  about  the  syndrome  of  untoward 
symptoms  which  cocain  may  produce  in  the  organism.  "Cocain  is 
contraindicated  in  persons  with  diseased  or  weak  heart.  Novocain 
seems  harmless,  and,  so  far  as  we  know,  can  be  applied  with  impunity 
even  during  pregnancy  and  lactation."     (Williger.) 

Ethyl  Chlorid. — Least  dangerous  is  anesthesia  with  ethyl  chlorid, 
which  may  be  used  to  advantage  for  producing  analgesia  in  peri- 
cemental diseases  of  the  anterior  teeth.  Many  practitioners  apply 
the  ether  spray,  especially  in  children,  for  the  production  of  brief 
anesthesia.  Only  small  quantities,  however,  should  be  employed,  as 
this  anesthetic  is  by  no  means  harmless  in  children,  and  even  small 
doses  of  it  may  produce  syncope.  It  should  never  be  employed  near 
an  open  flame  or  when  the  thermocautery  is  used,  owing  to  the  danger 
of  fire. 

Drugs  for  Injection. — The  danger  from  injected  drugs  is  compara- 
tively greater,  first,  because  the  toxic  effects  of  anesthetizing  solutions 
may  be  variable;  secondly,  because  the  injection  may  be  followed  by 
untoward  sequelae.  The  employment  of  excessive  doses  of  anesthetics, 
also,  any  idiosyncrasy  on  the  part  of  the  patient,  may  produce  serious 
intoxication.  If,  however,  the  operator  has  judged  correctly  the  char- 
acter of  the  surgical  intervention,  the  resistive  power  of  the  patient, 


72  INDICATIONS  FOR  LOCAL  ANESTHESIA 

and  the  maximal  dose,  i.  e.,  the  specific  toxicity  of  the  solution,  no 
accidents  are  ordinarily  to  be  expected  if  strict  asepsis  has  been 
observed. 

Local  Action  of  Novocain. — Locally  the  novocain  solution  recom- 
mended involves  no  risk  of  tissue  lesions  whatever.  Even  when  em- 
ployed in  large  quantities,  this  drug  behaves  innocuously,  and  is  very 
well  tolerated  by  the  tissues.  Necrosis  used  to  occur  when  high  per 
cent,  cocain  solutions  or  proprietary  preparations  containing  strongly 
escharotic  drugs  such  as  nitric  acid  were  still  in  vogue. 

Breaking  of  the  Needle. — A  possible  local  accident  to  be  reckoned 
with  is  the  breaking  of  the  hypodermic  needle,  the  fragment  sometimes 
disappearing  so  rapidly  in  the  mucosa  that  it  cannot  be  found  again. 
These  accidents  have  been  increasing  in  number  since  the  introduction 
of  conductive  anesthesia,  generally  in  mandibular  injection.  In  our 
opinion,  very  frequently,  lack  of  technical  skill  and  unfamiliarity  with 
the  correct  method  of  procedure  are  responsible.  Only  new  needles, 
if  possible,  or  those  that  have  been  used  but  a  few  times,  should  be 
employed. 

The  needle  may,  however,  break  without  the  operator's  fault,  if, 
for  instance,  the  patient  moves  his  head  or  gives  a  sudden  start.  If 
the  needle  fragment  has  been  sterile  and  free  from  rust,  it  seems  to  heal 
in  without  causing  any  trouble,  as  has  been  noted  in  several  cases. 
It  is  quite  possible,  however,  that  complications  may  be  produced 
by  the  fragment  later  on,  and  in  all  such  cases,  therefore,  an  attempt 
should  be  made  to  remove  it,  determining  its  location  by  an  ;\;-ray 
photograph,  and,  if  necessary,  having  it  removed  by  a  surgeon. 

Idiosyncrasy. — Without  any  fault  of  the  operator,  intoxications 
are  sometimes  caused  by  idiosyncrasies,  indisposition,  and  reduced 
power  of  resistance  in  the  patient.  It  is  hardly  possible  to  know  or 
diagnosticate,  in  advance,  the  patient's  disposition  to  react  abnormally 
to  certain  drugs.  There  are  persons  who  do  not  tolerate  cocain  and 
exhibit  grave  toxic  symptoms  even  after  the  minutest  doses.  Others, 
again,  are  indifferent  to  large  doses,  and  do  not  exhibit  the  desired 
anesthesia.      Still   others   who   do   not   tolerate   alypin,    for   instance. 


DANGERS  OF  LOCAL  ANESTILESIA  73 

react  perfectly  normally  to  other  salts,  as,  for  instance,  novocain, 
and  vice  versa. 

Very  frequently,  by  way  of  anamnesis,  the  details  of  such  peculiarities 
may  be  learned,  in  the  same  way  as  a  hemophiliac  cannot  be  recognized 
at  first  sight,  and  information  must  be  previously  obtained  from  the 
patient  himself. 

At  all  events,  caution  is  required  with  patients  who  complain  of 
palpitation  almost  immediately  after  the  introduction  of  the  needle,  or 
assume  a  threatening  color  of  the  face.  In  doubtful  cases  small 
quantities  and  weak  doses  should  be  employed  at  the  start. 

Shock  and  Collapse. — Shock  is  of  great  importance  during  anesthesia. 
The  psychic  shock  is  invariably  greater  in  local  than  in  general  anes- 
thesia, the  patients  imagining  that  they  are  to  undei-go  an  operation 
while  fully  conscious.  Hysterical  and  highly  nervous  patients  are 
difficult  to  persuade  to  submit  to  local  anesthesia,  owing  to  their 
reduced  resistance  to  psychic  shock.  They  exhibit  conditions  of  ex- 
citement and  collapse  which  may  assume  the  proportions  of  syncope. 
Serious  hysteria,  therefore,  is  a  contraindication  to  local  anesthesia. 
Cases  have  been  reported  in  which  the  patients  collapsed  before  the 
injection,  and  expired  from  shock  before  any  anesthetic  whatever 
had  been  applied.  Even  the  slightest  pain  on  introducing  the  needle 
may  suffice  to  produce  syncope  or  serious  collapse. 

In  nervous  patients  of  low  resistance  and  in  those  without  self- 
restraint  or  courage,  special  persuasion  is  required  to  dissipate  all  fear 
before  the  operation.  Herein  only  that  operator  will  be  invariably 
successful  who,  by  his  skill,  training,  and  familiarity  with  the  method 
of  procedure,  is  capable  of  fully  keeping  his  promise.  It  is,  therefore, 
a  great  mistake  for  an  operator  to  guarantee  full  success  before  the 
operation,  since,  in  case  of  failure,  he  undermines  his  reputation. 
Besides  being  most  unprofessional  and  unscientific,  such  a  guarantee 
is  more  apt  to  arouse  suspicion  than  confidence  in  an  intelligent 
patient. 

Antidotes  in  Collapse. — A  number  of  effective  measures  may  be 
adopted  in  case  of  disquieting  symptoms.  In  light  affections,  such  as 
palpitation,  rapid  pulse,  pallor,  perspiration,  and  trembling,  from  5  to  7 


74  INDICATIONS  FOR  LOCAL  ANESTHESIA 

drops  of  camphorated  validol  in  a  little  water  are  given  internally; 
in  more  serious  affections  amyl  nitrite,  from  i  to  3  drops  on  a  napkin, 
may  be  inhaled. 

Validol  is  a  colorless  liquid  of  mild,  agreeable  odor  and  refreshing 
taste.  It  consists  of  menthyl  ester  of  valerianic  acid  with  30  per  cent, 
of  free  menthol  and  10  per  cent,  of  camphor.  It  is  insoluble  in  water, 
but  readily  soluble  in  alcohol,  and,  if  given  internally  in  doses  of  from 
5  to  7  drops  in  water,  constitutes  an  ideal  analeptic  in  serious  cases  of 
collapse. 

Amyl  nitrite  is  a  clear,  volatile,  yellow  fluid  with  fruit-like  odor. 
On  inspiring  the  vapor,  flushing  of  the  face  occurs,  the  pulse  is 
accelerated,  and  vascular  dilatation  in  the  head  and  thoracic  region 
occurs.  The  increased  blood  supply  to  the  head  and  brain  counteracts 
the  anemic  conditions  present,  and  prevents  collapse. 

Disquieting  symptoms  of  a  lighter  nature  following  injection,  faint- 
ing or  syncope  may  be  combated  by  recumbent  position  of  the  head. 
In  serious  cases  the  heart  must  be  stimulated;  the  chest  is  wrapped 
in  wet  clothes,  and  cold  douches,  coffee,  or  a  hypodermic  injection 
of  oil  of  camphor  are  administered.  Some  of  these  agents  should  be 
kept  ready  for  use  in  any  injection,  as  immediate  application  is  essential. 

Injections  may  involve  two  further  unpleasant  accidents,  namely, 
postoperative  pain  and  hemorrhage. 

Postoperative  Pain. — Postoperative  pain  is  often  due  to  purely 
accidental  conditions  of  the  wound,  i.  e.,  remaining  sharp  alveolar 
splinters,  sloughing  of  the  margins  of  the  wound,  insufficient  bleeding 
and  clot  formation  after  excessive  ischemia,  injection  of  non-isotonic 
solutions  or  those  containing  strongly  toxic  agents,  insufficient  dis- 
infection of  the  field  of  operation,  infection  from  extraction  with 
unclean  instruments,  or  the  patient's  touching  the  wound  with  septic 
fingers,  also  from  food  debris,  all  of  which  can  be  averted  by  suitable 
precautions. 

While  it  is  irrefutable  that  every  anesthetized  wound  will  pass 
into  a  state  of  more  or  less  pronounced  hyperesthesia,  from  which  it 
returns  to  normal  sooner  or  later,  yet  from  personal  experience  we  feel 
certain   that  after  a  correctly   performed   injection   no   postoperative 


DANGERS  OF  LOCAL  ANESTLIESLA  75 

pain  is  to  be  expected.  If  all  the  necessary  precautionary  measures 
have  been  observed,  even  severe  periostitic  processes  behave  normally 
after  the  effect  of  the  anesthetic  has  worn  off.  In  such  cases,  for  the 
sake  of  prophylaxis,  we  invariably  prescribe  cold  compresses,  which 
have  proved  most  useful. 

The  greatest  mistakes  are  made  in  regard  to  asepsis — for  there  are 
still  many  operators  who  make  an  injection  without  having  previously 
disinfected  the  mucosa.  By  simply  swabbing  with  iodin,  as  described 
above,  the  great  danger  of  infection,  frequently  followed  by  edema, 
is  avoided. 

A.  Cohn,  of  Berlin,  reports  an  interesting  case  in  this  connection: 
"A  patient,  aged  twenty-seven  years,  asked  me  to  extract  an  upper 
third  molar  affected  with  pericementitis.  The  injection  and  extrac- 
tion were  entirely  successful.  About  four  hours  after,  postoperative 
hemorrhage  occurred,  with  a  sensation  of  heaviness  in  the  left  limb. 
The  hemorrhage  was  readily  stopped.  The  following  day  grave  symp- 
toms of  blood  poisoning  occurred,  combined  with  paralysis  of  the  left 
arm  and  leg,  which  led  me  to  suspect  intoxication  by  novocain-supra- 
renin.  This  diagnosis  had  to  be  abandoned  when  the  following  day 
the  right  side  also  became  paralyzed.  It  was  then  ascertained  that, 
despite  careful  injection,  streptococci  had  caused  embolism  in  the 
lumbar  region,  producing  paralysis  of  the  legs,  which  has  not  yet 
disappeared  (two  years  after),  while  the  other  symptoms  vanished. 
This  accident,  therefore,  must  be  regarded  as  indirectly  due  to  local 
anesthesia." 

Postoperative  pain  after  injection  is  of  psychic  origin  in  many  cases, 
as  Cieszynski  has  pointed  out.  His  assertion,  however,  that  after- 
pain  most  frequently  follows  pulp  treatment  under  anesthesia  cannot 
be  maintained,  since  the  normal  solution  always  yields  a  most  favorable 
result. 

Therapeutic  Measures  in  Postoperative  Pain. — Postoperative  pain 
is  counteracted  therapeutically  by  internal  administration  of  aspirin 
or  pyramidon  (0.5  gram  per  dose).  In  wounds,  tamponing  with  novo- 
cain, as  has  been  indicated,  renders  surprisinglj'  good  service.  In  all 
cases  of  inflammation  of  wounds  novocain  powder  is  applied.     The 


76  INDICATIONS  FOR  LOCAL  ANESTHESIA 

cavity  of  the  wound  is  carefully  cleansed  and  sterilized  with  hydrogen 
peroxid  and  a  lo  per  cent,  aqueous  solution  of  chlorophenol,  and  a 
layer  of  about  2  mm.  thickness  of  novocain  powder  (from  0.5  to  i  gram) 
is  introduced,  and  a  gauze  tampon,  saturated  with  10  per  cent,  iodo- 
form, which  also  has  been  previously  charged  with  novocain  powder, 
is  applied  with  light  pressure.  For  some  time  the  writer  has  convex 
niently  employed  a  powder-spraying  syringe,  from  which,  on  com- 
pressing a  rubber  bulb,  pure  novocain  is  blown  through  a  hard  rubber 
tube  which  is  held  close  to  the  wound  (see  Fig.  6).  This  procedure, 
consisting  of  disinfection  of  the  wound  and  novocain  tamponade,  is 
repeated  every  twenty-four  hours,  when  the  healing  of  the  wound  can 
be  left  to  itself  without  any  further  therapeutic  aid.  (See  chapter  on 
Anesthesia  in  the  Therapy  of  Inflammation,  p.  97.) 


Syringe  for  spraying  novocain  powder. 

In  cases  of  severe  inflammation  with  general  depression  due  to 
pain  from  pulpitis  and  pericementitis,  doses  of  morphin  internally  are 
warmly  recommended,  especially  half  an  hour  before  induction  of 
anesthesia  or  extensive  dental  operations.    The  formula  is  as  follows: 

Morpliin 0.2 

Hyoscin 0.005 

Distilled  water 10. o 

From  6  to  8  drops  in  a  tablespoonful  of  water. 

Besides  the  pronounced  sedative  effect  of  this  dose,  the  wound  heals 
better  and  with  less  reaction  under  the  protection  of  anesthesia,  hence 
anesthesia  plays  an  important  role  in  the  therapy  of  inflammations 
(see  p.  97).       Its  extensive  application  is  specially  indicated  in  den- 


THE  OPERATOR'S  RESPOXSIBILITY  77 

tistry,  and  strong  emphasis  should  be  laid  upon  this  excellent  method. 
With  this  therapy  by  anesthetization  in  view,  the  writer  compounded 
his  arsenic  paste,  which  contains  arsenous  acid,  novocain,  aa  4.0; 
thymol,  iodoform,  aa  0.5;  glycerin,  chlorophenol  crystals,  aa  enough 
to  make  a  paste;  to  be  incorporated  in  asbestos  fiber.  This  paste  has 
proved  most  efficient  as  tested  by  many  practitioners. 

Postoperative  Hemorrhage. — Postoperative  hemorrhage  caused  by 
injection  is  very  rare  indeed.  It  is  arrested  according  to  the  principles 
recommended  by  Williger,  the  chief  measure  being  tamponade.  A 
normally  bleeding  wound,  however,  should  never  be  dressed  with 
tampons.  Novocain  tamponade  is  only  superficial,  the  formation  of 
granulating  tissue  or  blood  clot  in  the  fundus  of  the  wound  not  being 
inhibited. 

All  in  all,  the  complications  that  may  arise  during  or  after  local 
anesthesia  are  far  less  numerous  and  not  as  serious  as  those  involved 
in  general  anesthesia;  consequently,  the  prognosis  in  the  latter  is  far 
more  uncertain  and  unfavorable  than  in  local  anesthesia.  In  this  point 
also  the  writer's  view  fulh-  coincides  with  that  of  Braun. 

THE    OPERATOR'S   RESPONSIBILITY 

The  patient's  risk  in  local  anesthesia  varies  according  to  the  opera- 
tor's skill,  and  therefore  it  cannot  be  too  strongly  emphasized  that 
local  anesthesia  demands  from  the  operator  a  specially  advanced 
technical  and  scientific  education,  which  can  be  acquired  only  by 
practice  and  experience. 

The  operator's  duty  is  specially  serious  owing  to  the  fact  that  he 
has  to  anesthetize  as  well  as  to  operate.  For  as  the  extent  and  the 
depth  of  the  anesthesia  can  be  calculated  only  by  the  one  who  has 
induced  it,  it  therefore  seems  imperative  that  the  operator  himself 
should  make  the  injection.  Of  course,  his  duties  are  thus  much  greater 
than  if  he  performs  an  operation  under  general  anesthesia.  The 
anesthetist,  therefore,  must  possess  great  technical  skill  and  ability, 
circumspection,  clearness  of  observation,  and  presence  of  mind,  coupled 
with  wide  experience  and  enthusiasm. 


78  INDICATIONS  FOR  LOCAL  ANESTHESIA 

During  the  operation,  an  assistant  should  carefully  watch  the  heart 
and  lungs,  without,  however,  neglecting  the  local  requirements  and 
conditions  of  the  operation.  Besides  having  a  thorough  knowledge  of 
the  surgical  conditions,  the  operator  must  be  master  of  the  anatomy 
of  the  respective  area.  He  must  know  all  secondary  symptoms  that 
may  arise  during  or  after  the  injection,  and  must  prepare,  simultaneously 
with  the  instruments  for  anesthesia  and  operation,  all  things  necessary 
for  emergencies,  such  as  amyl  nitrite,  validol,  oil  of  camphor,  and 
a  Pravaz  syringe.  By  ready  observation  of  untoward  symptoms 
accidents  can  generally  be  prevented  or  so  counteracted  as  to  avert 
serious  danger.  The  symptoms  of  approaching  danger  are  facial 
pallor,  perspiration,  shallow^  respiration,  irregular  pulse,  dilatation  of 
the  pupils,  and  others. 

It  is  imperative  not  to  leave  in  the  waiting  room  by  themselves  or 
without  supervision  locally  anesthetized  patients  who  have  to  wait  for 
some  time  before  the  operation,  but  to  observe  them  continually. 

The  following  alarming  case  has  been  reported  to  the  writer:  A 
practitioner  had  induced  novocain-suprarenin  anesthesia  in  the  max- 
illary mucosa  of  a  lady  who  had  but  just  recovered  from  influenza. 
Two  c.c.  of  the  solution  had  been  injected.  After  injecting,  the  operator 
left  the  surgery  for  the  laboratory  in  order  to  remove  the  needle,  it  having 
stuck  firmly  in  the  syringe.  -  Upon  returning  after  not  more  than  one 
minute,  he  saw,  to  his  astonishment,  the  patient  in  a  helpless  condition, 
having  fallen  back  in  the  chair  and  being  wedged  between  seat,  arm- 
rest, and  back.  The  head  was  deeply  reclined,  respiration  was  difficult 
and  slow,  the  pupils  dilated,  the  facial  color  cyanotic;  in  short,  all 
symptoms  typical  of  approaching  asphyxia  were  present.  With  great 
effort  he  lifted  the  entirely  insensible  patient  from  the  chair,  and  laid 
her  on  the  floor.  Respiration  ceased,  and  artificial  respiration  was  in- 
duced, which  proved  successful  after  about  two  minutes.  The  patient 
recovered  relatively  quickly  after  cold  cloths,  fresh  air,  and  amyl 
nitrite  had  been  applied,  and  despite  the  serious  character  of  the 
collapse  was  able  to  be  sent  home  by  carriage  after  one  hour. 

This  accident  is  a  further  proof  of  the  necessity  of  having  a  third 
person  present  for  assistance  in  every  case  of  local  anesthesia. 


THE  OPERATOR'S  RESPONSIBILITY  79 

Anamnesia. — The  operator,  before  inducing  anesthesia,  must  ex- 
amine the  patient's  heart,  lungs,  and  nervous  condition.  The  dentist 
in  many  cases  will  be  able  to  gather  from  an  accurate  anamnesia  the 
information  necessary  for  making  his  dispositions,  individually  gauging 
the  dose  to  be  injected,  calculating  the  time  of  waiting,  etc. 

Harmlessness  of  the  Normal  Solution. — In  some  cases  it  may  be 
difficult  to  decide  whether  local  anesthesia  should  be  emploj'ed  at  all, 
or  whether  general  anesthesia  would  be  more  favorably  indicated. 
In  arteriosclerosis  and  nephritis  great  hesitancy  has  been  entertained 
in  injecting  anesthetizing  solutions,  in  the  former  owing  to  the  altered 
condition  of  the  vascular  walls,  which  often  do  not  tolerate  even  a 
moderate  change  in  blood  pressure  as  produced  by  suprarenin,  in  the 
latter  owing  to  the  danger  of  intoxication  involved  in  the  passage  of 
the  anesthetic  through  the  diseased  kidney.  Every  anesthetic  is 
absorbed  by  the  blood  and  excreted  by  the  kidney,  which  is,  however, 
a  harmless  process  when  normal  doses  are  employed. 

The  weak  0.5  and  i  per  cent,  novocain-thymol  solution  with  the  small 
addition  of  suprarenin  must  also  be  regarded  as  an  agent  which  in 
such  cases,  even  in  diabetics,  renders  excellent  service  and  involves 
no  danger  for  the  life  or  health  of  the  patient.  Cocain  solutions, 
even  the  weakest,  cannot  be  cautioned  against  too  urgently.  These 
statements  are  fully  corroborated  by  Braun,  who  has  collected  con- 
vincing evidence  from  a  great  number  of  clinical  cases  (see  p.  39). 

From  these  observations  it  appears  that  the  anesthetist  has  a  great 
responsibility  toward  the  patient,  as  he  is  liable  for  every  damage, 
even  the  smallest,  inflicted  upon  the  patient  by  his  negligence.  Thus 
in  local  anesthesia  fulfilment  of  duty  must  be  of  prime  consideration, 
and  the  operator's  conscience  must  be  clear  in  regard  to  his  perfect 
mastery  of  the  science  and  technique  of  anesthesia. 

To  be  safe  in  case  of  any  accidents,  the  findings  of  the  examination, 
and  the  composition,  dosage,  and  quantity  of  the  solution  injected 
should  always  be  noted  before  inducing  local  anesthesia.  Such  a  record 
is  the  best  proof  for  the  operator's  conscientiousness,  and  is  always 
■of  decisive  importance  in  legal  proceedings. 


80  INDICATIONS  FOR  LOCAL  ANESTHESIA 


ACCIDENTS  AFTER  NOVOCAIN  INJECTIONS 

Serious  intoxications  after  injection  of  novocain  solution  have  never 
been  observed  by  the  writer  personally,  unless  he  were  to  regard  one 
case  of  narcotic  slumber  after  anesthesia  as  one  of  dangerous  intoxi- 
cation.    This  case  was  as  follows: 

Narcotic  Slumber  after  Novocain. — Before  extracting  the  gan- 
grenous roots  of  a  lower  second  molar  in  a  strong  and  healthy  woman, 
aged  thirty-six  years,  local  anesthesia  of  the  mucosa  was  induced; 
3  c.c.  of  a  2  per  cent,  novocain-thjmiol  solution  were  employed,  to 
which,  immediately  before  injecting,  3  drops  of  fresh  synthetic  supra- 
renin  in  I  to  looo  solution  had  been  added.  The  injection,  as  in  all 
patients  of  strong  constitution,  was  completed  without  notable  pain. 
The  period  of  waiting  for  the  establishment  of  perfect  anesthesia^ 
owing  to  the  tardiness  of  diffusion  in  the  mandible,  was  calculated  at 
fifteen  minutes,  and  in  the  meantime  two  upper  cavities  on  the  same 
(left)  side  were  to  be  excavated.  Very  soon  after  the  injection  (after 
about  one  minute)  the  patient  noted  considerable  numbness  in  the 
entire  left  mandible,  similar  to  that  produced  by  conductive  anesthesia, 
and  five  minutes  after  could  no  longer  feel  the  touch  of  the  rinsing 
glass  on  that  side  of  the  lip.  The  vascular  system  was  affected  at  the 
same  time,  a  slight  acceleration  in  pulse  occurring  for  some  two  or  three 
minutes,  whereupon  the  patient  lapsed  into  a  condition  of  half-slumber 
(sopor  or  coma),  and  seemed  to  have  difficulty  in  keeping  the  mouth 
open  for  the  preparation  of  the  defective  upper  teeth.  Pulse  and 
respiration  soon  resumed  their  normal  functions,  and  the  woman  gave 
the  impression  of  a  person  comfortably  sleeping.  As  in  hypnotic  sleep, 
she  answered  every  question,  and  rinsed,  opened  and  closed  her  mouth, 
in  short  followed  all  directions,  Avithout,  however,  opening  her  eyes 
or  realizing  what  she  was  doing.  The  upper  cavities,  which  had  been 
excavated  without  any  pain,  despite  close  proximity  to  the  pulp, 
were  filled  with  amalgam  after  inserting  a  protective  layer.  In  the 
meantime  twenty  minutes  had  elapsed  since  the  injection,  and  the 
two  badly  carious  roots  were  extracted.      Immediately  afterward  the 


ACCIDENTS  AFTER  NOVOCAIN  INJECTIONS  81 

patient  suddenly  straightened  herself  with  a  start,  opened  her  eyes 
and,  according  to  directions,  vigorously  rinsed  the  mouth.  From  this 
moment  she  appeared  as  if  changed,  acted  perfectly  normally,  and 
stated  that  a  pain  as  from  pressure  had  suddenly  startled  her.  She 
still  felt  the  numbness  in  the  left  mandible,  and  was  almost  ashamed 
when  told  of  her  having  slumbered.  She  boasted  of  always  having 
had  an  exceptionally  strong  constitution,  and,  as  if  to  excuse  herself, 
mentioned  that  her  system  always  reacted  with  extraordinary  readiness 
and  intensity  to  any  medicament.  To  this  peculiarity  she  ascribed 
the  light  slumber  following  the  injection,  saying  that  the  normal 
dose  evidenth'  had  affected  her  very  strongly.  She  did  not  know  what 
operations  had  been  made  in  her  mouth,  and  was  glad  to  hear  that 
her  upper  bicuspids  had  been  filled  in  the  meantime.  The  patient  left 
in  normal  possession  of  her  senses  and  feeling  quite  well,  nor  did  she 
experience  any  further  sequelae. 

In  the  writer's  opinion,  in  this  case  a  brief  "hypnotic"  slumber 
occurred,  due  exclusively  to  the  action  of  the  novocain  and  the  unusual 
susceptibility  of  the  patient's  system.  No  erotic  symptoms  were  noted 
in  this  case,  such  as  are  frequently  observed  in  general  anesthesia, 
also  sometimes  in  local  anesthesia  with  ethyl  chlorid  or  cocain.  Never- 
theless, such  symptoms  may  occur  in  sexually  highly  excitable  indi- 
viduals during  such  a  slumber  ensuing  after  novocain  injection,  which 
again  justifies  the  demand  that  not  only  during  general,  but  also 
during  local  anesthesia  a  third  person  should  be  present  to  avoid  all 
risks  of  suspicion. 

Since  the  lady's  excellent  state  of  health  in  the  case  cited  was 
corroborated  by  her  physician,  the  writer  is  inclined  to  consider 
the  extraordinary  effect  of  the  novocain  as  a  mild  intoxication,  or 
rather  an  irritation,  of  the  central  nervous  system,  produced  bj'  the 
exceedingly  small  quantity  of  0.06  novocain. 

Toxic  Action  of  Novocain. —  It  is  remarkable  that  in  the  above 
case  there  appeared  none  of  the  heretofore  observed  phenomena  of 
intoxication  by  novocain  which  Liebl  has  endeavored  to  test  in  his 
own  body.  Upon  injecting  0.75  gram  of  a  warm  10  per  cent,  solution 
in  his  right  thigh,  this  investigator  noted,  after  four  minutes,  "a  sudden, 
6 


82  INDICATIONS  FOR  LOCAL  ANESTHESIA 

strange  warmth  in  the  entire  body,  especially  in  the  region  of  the  liver, 
slight  malaise,  symptoms  of  nausea,  and  general  agitation,  but  no 
notable  change  in  pulse  or  complexion.  Two  minutes  later  slight  deaf- 
ness in  the  left  ear  set  in;  also  ocular  disturbances;  accommodation  in 
both  eyes,  especially  in  the  left,  being  possible  only  with  great  effort; 
and  diplopia.  Thirteen  minutes  after  the  injection  slight  pungent 
headache  on  the  left  side  was  noted;  after  seven  additional  minutes,, 
paresthesia  in  the  left  radialis  region."  After  about  one-half  hour's 
general  malaise,  normal  comfort  was  reestablished. 

The  slight  acceleration  of  pulse  shortly  after  injection,  as  noted 
in  the  case  reported  by  the  writer,  is  perhaps  to  be  attributed  to  the 
suprarenal  extract  rather  than  to  the  anesthetic,  since  it  has  not  been 
observed  with  pure  novocain-thymol  solutions.  Liebl  also  emphasizes 
that  no  change  in  pulse  and  complexion  was  noted, 

At  any  rate,  it  is  interesting  and  important  that  even  novocain, 
although  it  is  almost  devoid  of  irritating  action  on  the  tissues,  and  can 
be  tolerated  even  pure  without  disturbances  if  applied  topically  and 
externally,  may  occasionally  produce  irritation  of  the  central  nervous 
system,  even  in  a  dosage  far  below  the  maximal.  On  the  other  hand, 
it  must  not  be  overlooked  that  one  whose  organism,  as  in  the  case 
reported,  seems  to  react  even  to  the  lightest  chemical  stimuli,  and 
in  which  the  protoplasm  must  be  extremely  sensitive,  requires  an 
individual  maximal  dose  of  novocain  far  below  the  heretofore  accepted 
one,  although  in  the  case  reported  a  larger  dose  than  the  mean  was 
injected.  To  cite  Braun:  "Whether  and  in  what  intensity  novocain 
intoxication  occurs  in  the  central  nervous  system  by  no  means  depends 
only  upon  the  dose  of  novocain  introduced  into  the  blood,  but  also 
upon  the  time  employed  in  its  introduction.  If  introduced  into  the 
blood  suddenly,  or  in  concentrated  solution — in  our  own  case  the  injected 
solution  exceeded  in  its  action  that  of  the  usual  maximum  dose — imme- 
diate toxic  action  may  result  from  a  dose  which,  if  administered 
gradually,  i.  e.,  in  dilute  solution,  or  in  portions  at  intervals,  may 
not  produce  even  the  slightest  suggestion  of  an  intoxication  of  the 
central  nervous  system,  because  the  dose  of  novocain  in  the  capillaries 
of  this  organ  at  no  time  exceeds  the  toxic  dose." 


ACCIDENTS  AFTER  NOVOCAIN  INJECTIONS  83 

Klein  also  claims  to  have  observed  pronounced  symptoms  of  intoxi- 
cation from  novocain  in  5  cases,  3  of  which  he  attributes  to  com- 
plication with  functional  disorders  of  the  heart,  lack  of  resistance 
of  the  whole  organism,  and  abnormal  menstruation.  In  his  other  2 
cases,  however,  he  regards  novocain  as  exclusively  responsible  for 
serious  symptoms  of  collapse.  Just  as  the  case  reported  by  the  writer 
seems  to  illustrate  an  instance  of  extraordinary  action  of  novocain 
solution  that  must  be  judged  by  itself,  so  the  2  cases  of  intoxication 
reported  by  Klein,  which  apparently  cannot  be  ascribed  to  any  other 
causes,  must  be  regarded  as  abnormal  exceptions  to  the  rule.  From 
the  writer's  own  experience  with  the  use  of  novocain,  now  extending 
over  a  period  of  six  years,  he  can  only  once  more  emphasize  its  eminent 
advantages  over  cocain,  even  though  novocain,  as  we  have  seen,  may 
occasionally  produce  untoward  secondary  effects.  Until  now  these 
cases  have  been  of  such  a  tolerable  and  insignificant  nature,  and  so 
far  above  comparison  with  cocain  cases,  that  novocain  loses  none  of  its 
great  superiority  in  regard  to  the  relatively  almost  complete  absence 
of  irritation.  A  local  anesthetic  "surely  possesses  extremely  favorable 
properties,  if,  like  novocain,  it  occasionally  produces  relatively  harm- 
less symptoms  of  slight  intoxication,  which  cannot  be  compared  for 
one  minute  with  the  ghastly  clinical  picture  of  cocain  intoxication, 
and  does  it  only  under  conditions  specially  favorable  for  the  appearance 
of  symptoms  of  absorption,  that  is,  in  a  10  per  cent,  solution  at  body 
heat,  and  only  in  the  high  dose  of  0.75  gram,  as  Liebl  definitel}' 
established,  which  is  never  employed  in  local  anesthesia.  Even  0.4 
gram  of  a  10  per  cent,  solution  produces  no  toxic  symptoms."  Thus 
cases  of  intoxication  from  novocain  are  very  exceptional,  and  no 
great  importance  can  be  attached  to  them,  since  the  vast  majoritj' 
of  experiences  with  this  drug  have  been  extraordinarily  favorable,  as 
Klein  fully  acknowledges. 

Personally,  in  a  practice  comprising  over  15,000  cases,  the  writer 
has  not  had  a  single  serious  case  of  intoxication  after  injection,  while 
he  will  ever  remember  the  grave  accidents  after  cocain  injections. 
Nevertheless,  the  few  interesting  observations  of  abnormal  action  of 
novocain  emphasize  the  old  experience  that  individual  discrimination 


84  INDICATIONS  FOR  LOCAL  ANESTHESIA 

must  be  made  in  the  employment  of  every  drug,  and  must  positively 
be  reckoned  with  in  all  cases.  Cocain,  moreover,  readily  produces 
general  disorders,  and  is  known  to  be  responsible  frequently  for  local 
processes  of  gangrene  in  the  injected  tissue,  especially  if  the  solution 
is  not  absolutely  pure.  Such  processes  have  never  been  noted  after 
novocain,  injections  of  which  are  followed  by  postoperative  pain  only 
in  extremely  rare  cases,  while  with  cocain  this  is  almost  the  rule. 

Hysterical  Attacks  after  Novocain. — Several  cases  of  hysterical 
attacks  following  novocain  injection  have  been  reported,  one  by  Kehr,i 
one  by  Knoche,  of  Gotha,  and  one  by  Jelonek,  of  Duisburg.  In  all 
these  cases  the  patient  was  subject  to  hysteria,  which  broke  out  under 
the  added  stimulus  of  novocain  injection.  In  the  last  case  reported, 
the  patient  had  formerly  taken  novocain  and  had  tolerated  it  well, 
which  proves  that  the  novocain  had  produced  no  specifically  toxic 
effect,  but  was  merely  the  final  contributing  factor  to  a  long  preparing 
new  hysterical  outbreak,  the  predisposition  to  which  was  greatly 
pronounced  at  the  time  of  the  last  injection,  while  during  previous 
injections  the  disease  lay  dormant.  All  the  details  of  this  last  case 
confirm  our  opinion  of  the  infinitesimal  danger  of  intoxication  from 
novocain,  which  has  been  found  to  be,  and  for  the  present  remains, 
the  best  and  least  toxic  anesthetic.  Its  relative  toxicity,  to  quote 
Braun  once  more,  "is  incomparably  smaller  than  that  of  all  hereto- 
fore known  local  anesthetics."  In  dental  disorders  "the  low  toxicity 
of  novocain  plays  naturally  a  most  important  role."     (Braun.) 

These  cases  reported  corroborated  what  has  already  been  discussed, 
namely,  that  even  entirely  harmless  doses  of  novocain  occasionally 
may  act  toxically  by  producing  a  spasm  in  already  established  nervous 
diseases,  above  all  in  hysteria.  These  spasms,  however,  would  have 
been  induced  by  any  other  nerve  irritation.  The  procedure  of  injection 
and  operation  in  itself  is  an  unusual  experience  which  a  highly  excitable 
patient  overcomes  only  with  difficulty,  or  not  at  all.  In  hysteria, 
therefore,  as  has  been  said  before,  special  precaution  is  required  on  the 
part  of  the  operator. 

'  Deutsche  Monatsschrift  fur  Zahnheilkunde,  January,  1910. 


IXDICATIOA'S  FOR  LOCAL  ANESTHESIA  85 


INDICATIONS  FOR  LOCAL  ANESTHESIA 

The  question  as  to  when  local  anesthesia  is  indicated  cannot  be  solved 
within  the  limitations  of  this  book,  as  it  depends  more  or  less  upon 
the  conditions  presented  in  each  individual  case.  For  the  dentist, 
local  anesthesia  offers  a  wide  field  of  application,  and  in  its  present 
state  of  perfection  is  most  favorably  indicated.  Dentistry,  being  a 
branch  of  minor  surgery,  should  employ  this  method  all  the  more, 
since  in  major  surgery  local  anesthesia  is  rapidly  gaining  ground, 
and  is  destined  to  be  applied  in  the  future  even  almost  universally. 
The  possibility  of  local  anesthesia  should  always  be  considered  before 
resorting  to  general  anesthesia,  and  not  vice  versa,  as,  unfortunately, 
many  dentists  are  still  in  the  habit  of  doing.  Most  of  these  men  do 
not  sufficiently  master  the  method  of  local  anesthesia  and  do  not  have 
sufficient  interest  in  their  profession  or  in  their  patients  to  remedy 
this  deficiency  in  their  knowledge.  It  is  the  writer's  firm  conviction 
that  the  modern  dentist  should  make  the  same  progress  in  this  special 
branch  of  his  profession  as  he  has  always  made  in  the  purely  technical 
branches. 

Dental  Surgery. — In  dental  surgery  the  method  of  injection  can 
be  employed  in  an  infinite  variety  of  ways,  and  it  is  needless  to  enter 
into  a  further  discussion  of  this  familiar  field.  Besides  extractions, 
all  incisions  in  the  mucosa,  resections  of  roots,  bone  chiselling,  cystic 
operations,  partial  resections,  extirpation  of  small  tumors,  etc.,  come 
under  this  heading.  In  all  major  surgical  operations,  before  inducing 
anesthesia,  the  patient's  head  is  protected  with  the  head  wrap  indicated 
by  J.  Witzel.  A  sterilized  napkin  is  laid  over  the  hair,  and  fixed  at 
the  neck  with  a  safety  pin  (see  Fig.  7). 

Dentinal  and  Pulpal  Anesthesia. — \'arious  authors  have  recommended 
the  method  of  injection  for  dentinal  and  pulpal  anesthesia.  Its  appli- 
cation in  the  preservative  treatment  of  teeth  is,  indeed,  most  opportune. 
The  principles  governing  the  technique  of  anesthesia  are  the  same 
for  preservative  interventions  as  those  for  the  surgical  measures 
described   abo\-e.     The   purpose  of  injection   also   remains  the  same, 


86 


INDICATIONS  FOR  LOCAL  ANESTHESIA 


i.  e.,  production  of  painlessness,  regardless  of  the  nature  of  the  operation 
to  be  performed  under  the  anesthesia. 

Root  Treatment  under  Anesthesia  in  One  Sitting  in  Cases  of  Pul- 
pitis Contraindicated. — The  employment  of  local  anesthesia  in  treat- 
ing teeth  with  diseased  pulps  should  be  limited,  as  it  involves  various 
disadvantages  which  will  be  pointed  out  briefly  here,  as  follows: 
Unless  a  most  painstaking  diagnosis  of  the  tooth  to  be  treated  has  ■ 

Fin.  7 


Head  protection,  designed  by  J.  Witzel. 

been  made,  local  anesthesia  should  not  be  employed;  for  as  soon 
as  the  anesthetic  begins  to  act,  important  diagnostic  symptoms  about 
the  tooth,  especially  pain,  are  eliminated,  and  we  are  no  longer  able 
to  secure  proper  definition  in  our  work.  The  same  is  true  even  in 
simple  anesthesia  of  the  dentin. 

Injection    Suitable    for    Dentinal    Anesthesia. — After    it    had    been 
ascertained  that  no  drug  introduced  directly  into  the  cavity  or  applied 


INDICATIONS  FOR  LOCAL  ANESTHESIA  87 

to  the  dentin  for  the  produetion  of  anesthesia  acted  with  sufficient 
certainty  and  without  danger  to  the  vital  pulp,  experiments  with 
injection  anesthesia  were  conducted  for  this  purpose.  These  experi- 
ments with  novocain-thymol  solution,  in  the  writer's  experience,  have 
yielded  such  splendid  results  in  regard  to  the  efficiency  and  harmless- 
ness  of  this  anesthetic,  that,  in  his  opinion,  the  injection  method  is 
at  present  the  best  for  dentinal  anesthesia.  If  before  the  anesthesia 
the  condition  of  the  pulp  has  been  accurately  ascertained  by  the  in- 
duction current,  we  can  carry  out  our  measures  without  jeopardizing 
the  metabolism  in  such  teeth,  and,  in  some  cases,  fill  the  tooth.  After 
the  anesthesia  has  worn  ofi,  the  pulp  will  exhibit  a  slightly  reduced 
hypersensibility,  and  will  soon  return  to  normal  conditions.  According 
to  Euler's  and  Scheff's  experiments,  no  danger  exists  for  the  pulp, 
provided  that  the  technique  together  with  the  precautionary  measures 
have  been  carefully  followed.  It  is,  indeed,  a  blessing  for  highly  sensi- 
tive persons  to  have  the  tormenting  pain  abolished  which  is  usually 
produced  by  any  attempts  at  excavating  the  dentin  in  their  teeth. 

The  injection,  as  is  well  known,  simultaneously  with  analgesia,  also 
produces  anemia,  which  is  characterized  externally  by  a  paleness  of 
the  pulp  tissue.  Extreme  care  is  therefore  required  in  the  preparation 
of  the  cavity,  in  order  to  avoid  the  danger  of  inserting  a  filling  too 
closely  to  or  directly  upon  an  exposed  pulp  without  protecting  it,  by  an 
aseptic  pulp  capping,  or  of  overlooking  the  initial  stages  of  an  already 
existing  pulpitis.  Such  mistakes  are  likely  to  occur  owing  to  the 
indifference  of  the  pulp  artificially  produced  by  the  paralyzation  of  the 
nerve  tract.  Death  of  the  pulp  would  be  the  inevitable  consequence 
of  such  treatment.  The  cocain-adrenalin  mixtures  which  were  formerly 
employed  for  the  purpose  of  dentinal  anesthesia  only  too  often  caused 
keen  disappointment,  as  numerous  pulps  that  had  been  anesthetized 
with  these  agents  before  treatment  of  the  tooth  subsequently  fell 
victims  to  atrophy  or  necrosis.  These  failures  were  justly  attributed 
in  part  to  the  adrenalin,  and  the  initially  higher  dose  was  consequently 
more  and  more  reduced.  Cocain,  which  is  still  frequently  used, 
possesses  in  itself  ischemic  properties  which  were  so  intensified  by 
the  formerl}^  practised  excessive  addition  of  an  adrenalin  preparation 


88  INDICATIONS  FOR  LOCAL  ANESTHESIA 

that  the  artificial  atrophy  of  the  injected  tissue  was  maintained  for 
an  appallingly  long  period  of  time.  Unless  the  pulp  was  exceptionally 
strongly  constituted,  it  was  incapable  of  recovery,  and  consequently 
doomed  to  mortification.  With  the  recommended  dosage  of  injecting 
fluid,  however,  the  process  of  absorption  seems  so  greatly  improved 
that  a  normal  pulp  is  not  affected  thereby. 

Quinin. — In  highly  sensitive,  hysterical,  or  neurasthenic  patients,' 
in  whom  anesthesia  is  contraindicated,  it  is  of  advantage  before  the 
operation  to  administer  internally  doses  of  quinin  sulphate,  0.5  gram, 
or  chloral  hydrate,  i  gram,  for  quieting  the  nervous  system  in  prepa- 
ration for  the  ordeal.  Le  Monnier,  of  Nizza,  is  said  to  have  been 
the  first  to  apply  quinin  in  dentistry,  according  to  his  own  report: 

"In  February  and  March  of  1887,  when  the  severe  earthquake  took 
place  in  Nizza,  I  had  occasion  to  observe  that  many  of  my  patients 
showed  so  much  nervousness  that  it  was  impossible  even  to  touch  their 
teeth.  The  agents  usually  employed  had  no  effect.  Especially  teeth 
with  advanced  caries  were  so  sensitive  that  they  could  not  be  excavated, 
even  after  the  application  of  caustics.  One  of  my  patients  was  seized 
with  general  neuralgia  of  the  head,  so  that  he  excused  himself  for  not 
keeping  his  appointment.  Several  hours  later  he  appeared,  however, 
and  was  treated.  I  noticed  that  he  did  not  make  the  usual  twitching 
motions,  and  learned  that  he  had  taken  a  large  dose  of  quinin  for  his 
neuralgia. 

"It  then  occurred  to  me  to  prescribe  for  another  similarly  nervous 
patient,  0.5  gram  of  quinin  sulphate,  to  be  taken  for  two  days.  The  same^ 
effect  as  in  the  former  case  was  observed,  and  his  teeth  could  be  filled 
during  the  next  sitting.  The  quinin  seemed  to  affect  the  patients' 
nervousness  in  such  a  way  as  to  reduce  the  sensitivity  of  the  teeth, 
this  systemic  treatment  being  much  more  effective  than  the  local 
application  of  caustics. 

"In  the  same  year  I  had  occasion  to  treat  a  woman  patient  who 
exhibited  the  same  symptoms,  and  again  I  prescribed  0.5  gram  of 
quinin  daily  for  two  days.  I  was  agreeablj^  surprised  to  see  the  patient 
return  the  following  morning  and  submit  to  the  operation  as  readily 
as  the  previous  patients.     My  experience  has  recently  been  frequently 


INDICATIONS  FOR  LOCAL  ANESTHESIA  89 

corroborated,  and  I  believe  that  in  quinin  sulphate  has  been  found  a 
valuable  addition  to  our  medication,  at  least  in  nervous  patients." 

Chloral  Hydrate. — Chloral  hydrate  also  (from  0.5  to  I  gram)  has  a 
similar  sedative  effect,  obtunding  the  brain  function,  reducing  at  the 
same  time  the  sensitivity  of  the  teeth.  Apropos  of  this  drug,  Seitz 
reports  as  follows:  "In  1899  a  young  woman,  aged  eighteen  years, 
who  was  undergoing  nerve  treatment  in  a  sanatorium,  presented  for 
dental  treatment.  She  had  had  a  misfortune  a  year  previously,  while 
telephoning  during  a  thunderstorm.  Lightning  struck  the  wire,  and 
she  fell  senseless  beside  the  apparatus.  When  she  regained  conscious- 
ness, several  hours  afterward,  hyperesthesia  of  the  entire  surface  of 
the  body  had  set  in,  intolerable  pain  being  caused  by  the  slightest 
touch.  In  a  year's  time  this  hyperesthesia  had  somewhat  abated 
after  treatments  of  various  sorts,  yet  it  had  remained  in  the  trigeminal 
region,  so  that  the  mere  touching  of  the  teeth  with  the  finger 
still  caused  great  pain,  and  for  the  time  being  dental  treatment  could 
not  be  instituted.  When,  however,  idiopathic  toothache  set  in,  every 
therapeutic  means  had  to  be  tried  to  give  relief,  and,  since  local 
application  of  chloral  hydrate  was  impossible,  the  internal  adminis- 
tration of  this  sedative  was  resorted  to.  The  patient  was  given  one 
powder  of  1.5  grams  in  wine  in  the  evening,  and  the  same  dose  on  the 
following  day,  one-half  hour  before  the  operation.  The  sensibility 
was  actually  reduced  to  such  a  degree  that  even  the  dental  engine 
could  be  employed.  During  the  operation  the  patient  was  in  a  semi- 
narcotic  condition,  completely  indifferent,  and  showed  not  the  least 
sign  of  pain.  Half  an  hour  later  she  was  able  to  return  to  the  sana- 
torium in  a  carriage.     No  secondary  symptoms  occurred. 

"Similar  cases  have  been  reported  in  the  July,  1900,  issue  of  Dental 
Office  and  Laboratory .  According  to  this  report  chloral  hydrate  was 
administered  in  doses  of  from  10  to  15  grains,  which  acted  promptly 
even  in  cases  of  extreme  nervousness,  in  which  all  attempts  at  local 
anesthesia  of  the  dentin  had  failed.  Further  experiments  with  this 
sedative  are  therefore  highly  desirable." 

From  personal  experiments  with  chloral  hydrate  (i  gram)  and 
morphin  (o.oi  gram)  for  the  reduction  of  sensibility,  we  have  come  to 


90  INDICATIONS  FOR  LOCAL  ANESTHESIA 

the  conclusion  that  internal  medication  of  this  nature  in  suitable  cases 
is  very  advantageous.  Anesthesia  sets  in  after  from  four  to  five  minutes, 
characterized  by  a  notable  reduction  in  the  sensibility  of  the  dentin, 
which  varies  in  different  individuals.  In  highly  excitable  persons  this 
effect  is  frequently  noted  to  a  remarkably  extensive  degree.  While 
harmless  in  itself,  this  method  has  one  disadvantage,  inasmuch  as  the 
certainty  of  success  is  not  invariably  uniform.  Before  either  general 
or  local  anesthesia,  however,  it  is  of  great  value,  in  fortifying  the 
ps3'chic  condition  in  nervous  patients.  Bromural  and  its  application 
will  be  discussed  on  page  102. 

In  my  experience,  direct  anesthesia  of  the  dentin  and  pulp  is  still 
an  unreliable  measure.  For  the  sake  of  completeness  I  shall  cite  from 
Dependorf's^  article  a  method  which  seems  most  suitable  for  pressure 
anesthesia:  Griffin  prefers  for  pressure  anesthesia  the  hypodermic 
tablets  No.  81,  of  Parke,  Davis  &  Co.,  which  contain  cocain,  morphin, 
and  atropin.  One-third  or  one-half  tablet  is  introduced  in  the  cavity 
on  a  minute  cotton  pellet  saturated  with  adrenalin,  and  allowed  to 
lie  for  a  few  seconds  on  the  exposed  pulp.  Novocain  tablets  are  better 
for  this  purpose.  Then  a  piece  of  unvulcanized  rubber  slightly  smaller 
than  the  cavity  is  laid  over  this  pellet,  and  gentle  pressure  is  exerted. 
If  the  patient  shows  the  least  sign  of  pain,  the  pressure  is  relinquished, 
to  be  again  gradually  increased,  without,  however,  causing  any  pain. 
In  approximal  cavities  the  rubber  is  first  firmly  pressed  against  the 
cavity  margins,  and  then  slightly  against  the  pulp.  Small  round- 
headed  instruments  are  not  suitable  for  this  purpose,  as  the^'  pierce 
the  rubber  and  do  not  permit  of  uniform  pressure.  Only  flat,  broad 
pluggers  should  be  used,  as  they  can  easily  be  lifted  up  without  dis- 
placing the  rubber.  After  from  one  to  two  minutes,  when  the  pressure 
is  no  longer  plainly  felt,  the  rubber  and  cotton  pellet  are  removed, 
the  pulp  chamber  is  opened,  and  the  pulp  can  then  be  immediately 
extirpated  without  pain  or  hemorrhage.  A  repetition  of  the  pressure 
anesthesia  within  the  pulp  chamber  is  rarely  necessary.  This  method 
is  most  convenient  in  exposed  pulps,  though  it  is  efficient  even  Avhen  the 

•Ergebnisse  der  Gesamten  Zahnheilkunde,  1910,  vol.  iii. 


INDICATIONS  FOR  LOCAL  ANESTHESIA 


91 


pulp  is  still  covered  with  a  thin  layer  of  dentin.  A  drop  of  adrenalin, 
a  few  cocain  crystals,  a  drop  of  formagen,  and  pressure  with  rubber  is 
all  that  is  required.  For  obtaining  complete  anesthesia.  Griffin  takes 
from  one-half  to  three  minutes. 

Anesthesia  with  Subsequent  Preservation  of  Vital  Pulp  Stumps 
Indicated. —  In  some  cases  the  pulp  stumps  in  the  roots  may  be  pre- 
served. In  hypertrophy  of  the  pulp  this  has  been  tried  very  success- 
fully. In  such  cases  anesthesia  oft'ers  the  enormous  advantage  of  ren- 
dering possible  the  exposure  and  amputation  of  the  coronal  portion 
of  a  diseased  pulp,  the  root  portions  of  which  are  capable  of  remaining 

vital. 

Fig.  8 


Pulp 


Pressure  anesthesia  in  exposure  of  the  pulp. 

Pressure  Anesthesia. — Just  as  the  method  of  injection  anesthesia, 
so  that  of  pressure  anesthesia  has  yielded  very  favorable  results  in 
these  cases.  The  uppermost  portion  of  the  pulp,  which  in  hypertrophic 
pulps  is  almost  insensible,  is  removed  with  a  sharp  spoon  excavator, 
and  upon  the  commonly  profusely  bleeding  pulp  a  layer  of  novocain 
powder  is  dusted,  over  which  a  cotton  pellet  saturated  with  i  to  looo 


92 


INDICATIONS  FOR  LOCAL  ANESTHESIA 


synthetic  suprarenin  is  laid,  which  is  finally  covered  with  a  larger  cotton 
dressing  (see  Fig.  8).  Then  with  a  pair  of  blunt  pliers  or  a  round-head 
plugger,  gradually  increasing  pressure  is  exerted  for  from  four  to  five 
minutes.  The  coronal  portion  of  the  pulp  can  then  be  painlessly  am- 
putated. From  this  method  very  favorable  results  have  been  derived 
in  very  resistant  pulps,  the  great  vitality  of  which  is  shown  by  the 
hypertrophic  neoformation  (see  Fig.  9).  The  hypertrophied  portions 
of  such  pulps  were  amputated  together  with  the  coronal  portions  under 
local  anesthesia  (see  Fig.    10).     The  carious  portion  of  the  cavity  is 

Fig.  9 


Polypoid  (hypertrophic)  degeneration  of  pulp,  symptom  of  great  vitalit}'  of  tissues. 

carefully  excavated  with  burs,  and  the  bleeding  pulp  stumps  are  sealed 
with  the  thermocautery  (see  Fig.  10).  A  layer  of  thinly  mixed  Fletcher 
cement  is  inserted,  and,  after  this  has  hardened,  the  cavity  is  filled 
with  ordinary  dental  cement  (see  Fig.  11).  Within  over  three  years 
none  of  the  teeth  thus  treated  have  caused  any  trouble,  but  react 
to  the  electric  current  like  healthy  teeth.  On  the  other  hand,  in  the 
writer's  opinion,  very  many  pulps,  including  all  those  in  sickly  persons, 
resist  every  attempt  at  preservation,  and  the  relatively  few  cases  of 
success  in  strongly  resistant  pulps  are  to  be  attributed  mainly  to  the 
unusual  power  of  resistance  of  the  pulpal  tissue. 


INDICATIONS  FOR  LOCAL  ANESTHESIA  93 

Fig.  10 


Thermocaitteri/ — -.-',"' 


Cauterized  pulp 

^^f"         stump 


-  Pulp 


Diagram  showing  preservative  pulp  treatment  in  hypertrophic  degeneration.     Second  stage:j  The 
anesthetized  vital  pulp  stumps  are  cauterized  with  the  thermocautery. 


Diagram  showing  preservative  pulp  treatment  in  hypertrophic  degeneration. 
Third  stage:    Filling  the  tooth. 


94  INDICATIONS  FOR  LOCAL  ANESTHESIA 

Root  Canal  Treatment. — Pulps  affected  with  pulpitis  must  be  sub- 
jected to  root  canal  treatment.  In  exposing  the  diseased  pulp  under 
anesthesia  a  part  of  the  coronal  portion  may  be  amputated,  but  no 
further  treatment  should  be  instituted  under  anesthesia.  Anesthesia 
is  especially  indicated  in  opening  into  those  teeth  which,  owing  to  the 
presence  of  pulp  stones,  are  affected  with  pulpitis,  especially  if  the 
crown  is  not  perfectly  preserved.  In  such  cases  the  writer  introduces 
his  readily  acting  caustic  dressing  as  indicated  above,  followed  several 
days  later  by  root  canal  treatment ;  generally  no  notable  pain  is  observed 
in  the  meantime. 

Root  canal  treatment  under  anesthesia  is  contraindicated  for  the 
additional  reason  that  the  fresh  pulp  tissue  which  has  not  been  coagu- 
lated by  the  dressing  clings  very  tenaciously  to  the  dentin  and  cannot 
be  entirely  removed,  as  experience  has  shown.  Even  the  cauterized 
pulps  of  incisors  and  canines,  which  are  so  suitable  for  total  extirpa- 
tion, tear  frequently  into  shreds,  the  complete  removal  of  which  is 
most  difficult  and  uncertain,  not  to  mention  the  difficulties  involved 
in  extirpation  of  the  pulps  in  bicuspids  and  molars.  Moreover,  the 
hemorrhage  in  the  deep  portions  of  pulp  stumps  is  very  difficult  to 
arrest,  creating  an  unsafe  edematous  zone  of  demarcation  at  the 
apical  foramen  which  disappears  only  gradually  after  subsequent 
pericementitis,  and,  in  case  of  infection  by  way  of  the  root  canal, 
produces  suppurative  pericementitis  which  seriously  endangers  the 
preservation  of  the  tooth. 

Pulp  debris  that  has  not  been  removed  becomes  the  cause  of  pro- 
tracted irritations  of  pulpitic  and  pericementitic  nature,  which  can  be 
combated  only  by  means  of  cauterization.  Even  granting  that  there  are 
many  teeth  which  remain  quiet  even  in  such  cases,  it  is  a  well-known 
fact  that  the  pain  in  pulps  may  be  of  very  varying  intensity.  We 
only  need  to  mention  the  case  of  patients  who  present  gangrenous 
teeth  without  ever  having  suffered  any  pain.  It  is  therefore  to  be  laid 
down  as  a  principle  that  anesthesia  should  never  be  employed  as  a 
means  for  ''rapid  cure"  in  pulp  and  root  canal  treatment,  else  dis- 
credit may  be  reflected  upon  the  invaluable  method  of  injection 
anesthesia  by  its  injudicious  application. 


INDICATIONS  FOR  LOCAL  ANESTHESIA  95 

Someone  might  suggest  that  pain  arising  after  such  treatment  must 
be  due  to  the  injection  or  the  toxicity  of  the  drug.  In  this  regard 
the  writer  fully  agrees  with  Schroder,  who  recently  issued  renewed 
warnings  against  abandoning  caustics  in  favor  of  local  anesthesia. 
Rapid  pulp  and  root  treatment  is  not  desirable,  yet  anesthesia  may  be 
emploj'ed  to  allay  the  pain  connected  therewith.  Anesthesia  is  a 
welcome  aid,  but  it  is  not  intended  to  take  the  place  of  caustics. 

Crown  and  Bridge  Work. — Local  anesthesia  is  gaining  more  and 
more  ground  also  in  crown  and  bridge  work.  Numerous  minor  opera- 
tions, such  as  the  grinding  down  of  sound  teeth  or  the  preparation  of 
roots,  are  so  painful  that  it  is  most  desirable  to  abolish  pain  and  insure 
the  patient's  comfort.  The  mode  of  application  of  novocain-thymol 
solution  remains  the  same  as  described.  Occasionally  the  mucosa  can 
be  anesthetized  by  novocain  tamponade  as  described  above,  or  by 
painting  the  gums  with  from  20  to  30  per  cent,  novocain  solution. 

Indications  in  General  Disease. — Local  injection  anesthesia  may  be 
applied  safely  in  arteriosclerosis,  diabetes,  nephritis,  cardiac  and  pul- 
monary disorders,  anemia,  chlorosis,  gestation,  and  lactation.  In 
these  conditions  novocain  alone  is  indicated  in  weaker  doses,  i.  e., 
Nos.  I  and  2  of  the  normal  solution.  Cocain  is  absolutely'  contrain- 
dicated,  especially  in  cardiac  and  pulmonary  disease,  as  substantiated 
by  Williger. 

Individual  Judgment. — In  local  anesthesia  a  great  deal  of  individual 
judgment  is  required.  The  operator  must  recognize  with  keen  insight 
what  quantity  and  dilution  is  indicated  in  a  given  case.  In  children 
a  smaller  quantity  and  weaker  dose  is  selected  than  in  robust  adults, 
and  in  the  feeble  aged  the  normal  dose  is  also  to  be  reduced.  Gen- 
erally, however,  in  healthy  old  persons  the  full  dose  may  be  employed, 
as  diffusion  in  the  bone  is  much  less  favorable  in  such  patients  than  in 
youthful  ones.  It  is  needless  to  say  that  convalescents  also  require 
special  care. 

Contraindications. — Novocain-thymol  solution  seems  contraindicated 
only  by  the  technical  impossibility  to  successfully  make  the  injection, 
as  in  ankylosis,  severe  purulent  periostitis,  and  phlegmon  so  ex- 
tended that  normal  tissue  in   the  vicinit^'  of  the  centre  of  infection 


96  INDICATIONS  FOR  LOCAL  ANESTHESIA 

can  not  be  reached.  It  is  also  contraindicated  in  stubborn,  especially 
excited  and  neurasthenic  patients  who  insist  upon  general  anesthesia. 
In  these  the  morphin-hyoscin  medication  should  be  tried  first,  as 
generally  an  injection  can  after  all  be  made,  which  in  cases  of  simple 
and  easy  extractions  is  decidedly  to  be  preferred  to  general  anesthesia. 
Local  anesthesia  cannot  be  recommended  in  cases  of  serious  hysteria, 
which  may  give  rise  to  the  complications  observed  even  after  novocain, 
within  recent  years. 

General  Anesthetics. — If  general  anesthesia  must  be  induced,  the 
writer  prefers,  like  Euler  and  Williger,  the  mild  anesthetics,  such  as 
ethyl  chlorid,  ethyl  bromid,  and  ether  to  chloroform.  The  general 
principle  is  that  the  smaller  and  easier  the  operation  the  less  the 
dangers  likely  to  arise. 

"After  all  these  observations  I  do  not  hesitate  to  maintain  that 
general  anesthesia,  above  all,  chloroform  anesthesia,  with  the  few  ex- 
ceptions enumerated,  is  unnecessary  in  operations  in  the  oral  cavity, 
and  that,  as  a  legal  expert,  I  should  be  unable  to  protect  an  operator 
from  indictment  in  case  of  fatal  accident  from  general  anesthesia." 
(Kupfer.) 

Drugs  for  Injection. — The  patient,  to  be  sure,  must  possess  a  certain 
amount  of  vitality  in  order  to  satisfy  the  requirements  of  anesthesia. 
It  is,  therefore,  important  to  select  such  a  method  of  injection  and 
such  a  solution  as  will  produce  the  least  toxic  symptoms.  Thus,  novo- 
cain, which  is  but  one-seventh  as  toxic  as  cocain,  is  to  be  preferred  in 
every  case,  without  jeopardizing  success  in  the  least.  As  novocain  is 
only  one-third  as  toxic  as  the  other  substitutes  for  cocain,  it  occupies 
the  place  of  preference  also  among  these  substitutes. 

The  extensive  application  of  local  anesthesia,  owing  to  the  growing 
prevalence  of  enervation  in  modern  life,  is  especially  called  for  in  dentis- 
try, even  for  very  minor  operations.  The  patients  often  demand  that 
the  mucosa  be  completely  anesthetized  before  the  hypodermic  needle 
is  inserted;  this  is,  however,  superfluous  if  the  proper  technique  is 
followed.  Local  anesthesia  should  be  not  applied  to  such  excess,  since 
the  most  important  diagnostic  aid  is  thereby  sacrificed,  as  has  been 
shown  previously. 


ANESTHESIA   IN  THE   THERAPY  OF  INFLAMMATION  97 

At  all  events,  local  anesthesia  deserves  the  place  of  preference  in  the 
prevention  of  pain  in  dentistry,  and  it  is  the  duty  of  every  conscien- 
tious practitioner  to  aspire  to  that  lofty  ideal  of  our  science  so  welcome 
to  patient  and  operator  alike.  General  anesthesia  is  and  must  be  a 
general  intoxication  which  is  never  free  from  risk  for  the  patient's 
life.  Such  a  risk  can  be  justly  regarded  as  non-existing  if  our  modern 
solutions  are  employed,  especially  the  generally  advocated  novocain 
solution  in  the  composition  indicated.  In  dental  operations,  moreover, 
the  doses  and  quantities  of  this  solution,  as  employed  in  each  case, 
are  fully  ef^cient,  though  far  below  toxicity. 

ANESTHESIA  IN  THE  THERAPY   OF  INFLAMMATION 

For  the  combating  of  inflammatory  processes  in  the  oral  cavity 
the  writer  recommended  as  early  as  1907  the  liberal  employment  of 
anesthesia,  and  first  introduced  into  dentistry  a  method  which  had 
already  proved  most  effective  in  other  branches  of  medicine. 

"The  chief  object  of  anesthesia  in  the  therapy  of  inflammations 
is  to  bring  the  anesthetizing  agent  in  such  frequent  and  intimate  con- 
tact with  the  wound  that  the  subjective  painful  sensations  are  pre- 
vented or  reduced  to  a  minimum."     (Spiess.) 

The  patient's  condition  corresponds  exactly  with  the  appearance  of 
the  wound  and  the  intensity  of  the  inflammation.  The  total  or  partial 
absence  of  pain  permits  of  a  safe  conclusion  as  to  the  total  or  partial 
absence  of  inflammatory  reaction. 

Practical  Experiences  in  the  Oral  Cavity. —  In  a  large  number  of 
throat  operations,  also  of  surgical  interventions  in  the  tongue,  the 
cheeks,  and  the  mucosa  of  the  lips,  anesthesia  has  been  therapeutically 
applied  by  Spiess  in  various  ways,  according  to  individual  cases. 
When  superficial  analgesia  proved  insufficient  for  these  operations, 
submucous  injections  were  made.  These  were  employed  also  in  post- 
operative treatment  in  cases  where  dressings  of  anesthetizing  agents 
were  technically  impossible.  The  object  was  to  anesthetize  wounds 
in  inflamed  tissue  areas  and  the  inflamed  tissue  itself,  and  to  keep 
both  in  an  analgetic  condition  as  long  as  possible. 


98  INDICATIONS  FOR  LOCAL  ANESTHESIA 

Tongue. — In  minor  injuries  of  the  tongue  due  to  an  awkward  bite, 
or  to  sharp  edges  and  corners  of  carious  teeth,  and  in  the  frequent  and 
intensely  painful  desquamations  at  the  tongue  margin,  pain  rapidly 
disappeared  after  several  applications  made  in  quick  succession. 

Coryza. — If  the  disagreeable  sensations  of  incipient  nasal  catarrh 
are  relieved  by  insufflation  of  orthoform  or  novocain  into  the  naso- 
pharyngeal cavity,  repeated  until  normal  sensation  is  reestablished,, 
coryza  can  be  aborted  with  absolute  certainty. 

Lacerations. — If  minor  bruises,  lacerations,  also  wasp  and  fly  stings 
are  painted  with  orthoform  or  novocain  in  the  form  of  a  thick,  watery 
paste  or  in  solution,  until  all  pain  has  ceased,  no  further  reddening  and 
swelling  of  the  wound  will  occur.  On  the  contrary,  the  edges  will 
be  smoother,  paler,  and  without  sensation,  the  wound  undergoing 
rapid  healing.  By  all  these  observations,  extending  over  a  long  period 
of  years,  the  fact  has  been  established  beyond  doubt  that  local  anes- 
thetics inhibit  pain;  that  wounds,  if  the  absence  of  pain  is  maintained 
by  means  of  analgesia,  heal  without  inflammation;  and  that  estab- 
lished inflammations  heal  in  a  very  short  time. 

Modifying  the  Process  of  Healing. — Numerous  experiments  have 
shown  that,  together  with  the  pain,  the  redness  also  disappears.  It 
was  heretofore  impossible  to  modify  an  inflammation  at  the  climax 
of  its  development  in  such  a  way  as  to  cause  the  redness  to  disappear. 
With  the  above  anesthetics  this  can  be  accomplished  in  a  very  short 
time,  often  within  a  few  minutes;  more — the  pain  can  be  absolutely 
abolished.  This  rapid  abatement  of  the  redness  can  be  explained  only 
by  assuming  a  direct  relationship  between  pain  and  redness,  in  opposi- 
tion to  Cohnheim's  theory.     It  simply  remains  to  establish: 

"  I.  That  in  the  same  way  as  the  irritation  of  sensory  nerves  produces 
hyperemia  by  way  of  reflex,  so  the  inhibition  of  this  irritation  prevents 
hyperemia  or  abolishes  it. 

"2.  That  therapeutic  treatment  should  be  directed  simply  and 
exclusively  against  the  irritation  of  the  sensory  nerves,  and  that  the 
normal  function  of  the  vessels  should  be  maintained. 

"3.  That  anesthesia  is  required  only  to  such  a  degree  as  to  inhibit 
reflex  action  and  to  abolish  in  the  parts  involved  the  changes  produced 
by  the  sensory  nerves  by  way  of  reflex." 


ANESTHESIA   IN  THE   THERAPY  OF  INFLAMMATION  99 

Examples  from  General  Pathology. — Insanity. — These  postulates 
are  entirely  fulfilled  in  the  cases  of  anesthesia  occurring  in  the  hysterical 
and  the  insane,  alienists  having  noted  many  cases  in  which  injuries, 
burns,  and  wounds  in  such  patients  healed  completely  without  any 
reaction  whatever.  Thus  it  has  happened  that  insane  patients  tore 
open  their  abdominal  wound  after  laparotomy,  pla^^ed  with  the  wound 
with  their  unclean  fingers,  and  nevertheless  made  an  uneventful  and 
complete  recovery. 

Hysteria. — Hysterical  persons  can  stick  pins  in  their  skin  without 
any  untoward  consequences.  In  one  case  of  hysteria,  the  patient,  who 
was  suffering  with  general  paralysis  of  sensibility,  dipped  his  hands 
repeatedly  in  boiling  water  without  being  scalded  in  the  least.  The 
explanation  may  be  that  the  afferent  nerves,  owing  to  the  existing 
paralysis,  could  not  be  stimulated,  and  the  reflexes  upon  the  vaso- 
motor nerves  remained  inert.  Since  the  influence  of  the  heat  was  only 
of  short  duration,  no  direct  thermal  scalding  effect  was  produced 
upon  the  tissues,  and  no  hyperemia  or  inflammation  occurred. 

Animal  experiments  with  spinal  anesthesia  have  confirmed  the  above 
observations,  the  anesthetized  tissue  exhibiting  no  blisters  or  even 
reddening  upon  being  touched  with  a  test-tube  filled  with  boiling  water. 

Local  Processes. — Not  in  hysteria  alone  is  the  sensory  sphere  par- 
al3-zed,  but  there  are  also  pathological  processes  in  which,  besides  the 
afferent  nerve  fibers,  the  sympathetic  nerves,  often  termed  trophic 
nerves,  are  affected.  Of  special  interest  to  us  are  the  cases  of  gangrene 
due  to  drugs,  in  which  the  above  factors  probably  play  a  part.  If 
carbolic  acid  is  allowed  to  act  too  long  and  too  intensely,  besides  the 
well-known  phenomena  of  thrombosis,  not  only  the  conductivity  of 
the  afferent  fibers  is  inhibited,  but  the  vessels  also  are  directly  affected, 
inasmuch  as  they  become  paralyzed,  and  their  function  is  destroyed 
in  the  same  manner  as  that  of  the  nerves.  Cold  in  sufficient  intensity- 
is  also  able  to  abolish  sensation,  as  shown  by  the  ether  spray.  If  its 
influence  is  unduly  prolonged,  the  vasomotor  nerves  permeating  the 
vascular  walls  are  directly  affected,  and  gangrene  ensues. 

While  anesthetization  of  the  afferent  nerves  promptly  prevents, 
or  combats  inflammation,  all   inflammatorj-  phenomena  appear  more 


100  INDICATIONS  FOR  LOCAL  ANESTHESIA 

rapidly  and  severely  if  the  sympathetic  nerve  branches  are  paralyzed, 
as  Samuel  has  proved  by  animal  experiments. 

Combating  Local  Irritability. — Pain,  which  is  a  specially  pronounced 
specific  sensation  of  discomfort,  hence  a  condition  of  conscious  sensa- 
tion, undoubtedly  intensifies  not  only  the  general  irritability,  but  also 
the  local  irritability  and  excitation  in  inflamed  areas  by  conscious 
and  wilful  acts,  furthermore  and  notably  by  way  of  unconscious 
reflexes,  i.  e.,  by  the  centripetal  (afferent)  nerve  supply  of  specially 
irritated  portions  of  the  brain.  This,  however,  is  after  all  not  the 
primary  or  most  important  cause  of  these  local  processes.  It  is,  there- 
fore, the  first  aim  of  therapeutic  measures  to  reduce  the  increased 
local  irritability — the  cause  of  the  abnormal  central  processes — either 
directly  or  by  generally  influencing  the  normally  or  pathologically 
sensitive  nervous  system.  The  former  in  light  cases  may  be  accom- 
plished by  very  simple  measures,  namely,  by  covering  and  soothing  the 
inflamed  areas.  Since,  however,  despite  the  protection  from  external 
stimuli,  owing  to  the  continually  recurrent  action  of  internal  tissue 
stimuli  the  local  irritability  may  gradually  increase  and  become 
excessive,  these  simple  measures  are  frequently  inadequate,  and  an 
attempt  must  be  made  to  modify  the  local  irritability  of  the  tissues 
themselves,  by  the  application  of  cold  or  heat,  whereby  the  dispo- 
sition to  abnormal  irritability  is  reduced,  and  the  blood  supply  and 
internal  process  of  repair  are  indirectly  regulated.  For  this  purpose, 
Spiess'  method  is  specially  efficient,  as  it  acts  in  both  directions, 
first,  by  the  thick  layer  of  orthoform  or  novocain  powder  furnishing 
protection  against  external  stimuli,  and  secondly  and  more  important, 
by  directly  preventing  the  irritability  of  the  morbid  tissue.  The  latter 
effect  is  obtained  to  a  specially  high  degree  by  morphin,  which  is  in- 
tended to  act  not  as  a  hypnotic,  but  merely  as  a  sedative;  for  it  is 
improbable  that  morphin  attacks  the  central  nervous  system  primarily. 
Such  direct  action  upon  the  nervous  centre  is  peculiar  to  chloroform 
and  ether,  while  morphin  affects  above  all  the  peripheral,  the  integu- 
mental  nerves,  and  reduces  the  irritability  of  the  central  nervous 
system  from  the  periphery.  Simultaneously  with  the  alteration  of 
the  tissue,  and  only  as  an  indirect  result  of  the  altered  activity  of  the 


ANESTHESIA   IN  THE   THERAPY  OF  INFLAMMATION  101 

nervous  system,  the  healing  process  commences  its  favorable  course, 
not  because  pain  is  abolished  or  the  pain-conducting  nerves  are  par- 
alyzed, but  because  the  source  of  pain  is  blocked,  and  the  cause  of 
increased  irritability  is  removed,  so  that  no  longer  any  abnormal 
influence  is  exerted  upon  the  nerves. 

Effect  of  Sedatives. — The  drugs  that  reduce  irritability,  therefore, 
act  best  at  the  beginning  of  the  disease,  or  when  the  equilibrium  of 
the  tissues  tends  already  to  return  to  normal.  The  favorable  action 
of  carbolic  acid,  locally  applied,  must  be  attributed  above  all  to  its 
anesthetizing  property,  and  it  appears  as  if  other  drugs,  the  favorable 
action  of  which  was  formerly  attributed  to  their  disinfectant  power, 
possess  the  same  sedative  effect.  The  local  application  of  morphin 
also  to  inflamed  tissue  denuded  of  epithelium  exerts  a  favorable  in- 
fluence, as  has  already  been  mentioned,  if  morphin  powder  is  allowed 
to  dissolve  on  the  mucosa,  or  if  a  few  drops  of  a  sufficient!}'  strong 
solution  are  applied  and  allowed  to  be  absorbed. 

Effects  of  Anesthesia. — "No  inflammation  will  develop  if  the 
reflexes  conveyed  from  the  centre  of  inflammation  by  way  of  the 
afferent  sensory  nerves  are  successfully  inhibited  by  anesthesia.  Rapid 
healing  in  an  inflammation  already  established  is  induced  by  anes- 
thetization of  the  centre  of  inflammation,  providing  such  anesthetiza- 
tion affects  only  the  sensory  nerves,  and  does  not  interfere  with  the 
normal  function  of  the  sympathetic  (vasomotor)  nerves."     (Spiess.) 

This  much  is  certain,  it  is  of  great  importance  to  withhold  external 
irritation,  and,  if  this  is  no  longer  possible,  to  treat  the  area  that  favors 
the  formation  of  internal  irritation  in  such  a  way  as  to  transform  the 
excess  of  sensibility  of  the  tissues  into  a  state  of  normal  sensibilit}', 
which   is  accomplished   by  anesthetics. 

Duration  of  Painlessness. — Process  of  Healing. — In  all  cases  which 
the  writer  has  had  occasion  to  observe  personally,  the  painlessness 
lasted  until  the  termination  of  treatment,  and  in  prophylactic  cases 
inflammation  of  the  wound  after  extraction  did  not  set  in,  which  other- 
wise, considering  the  severe  nature  of  this  operation,  would  surely 
have  occurred.  It  might  be  suggested  that  antiseptic  precautions 
alone   would   suffice   to   bring  about  a   mitigation   of    pain   and   sub- 


102  INDICATIONS  FOR  LOCAL  ANESTHESIA 

sequent  inflammation.  Judging  from  experience,  however,  the  new 
method  of  wound  therapy  marks  a  pronounced  improvement  in  the 
heaHng  process  over  the  older  procedures,  inasmuch  as  usually  no 
relapses  of  postoperative  pain  occur,  which  formerly  were  the  invariable 
rule.  The  process  of  healing  is  characterized  especially  by  the  absence 
of  pain.  Novocain  tamponade  is  particularly  useful  in  painful  wounds 
from  extraction  or  other  surgical  operations. 

We  must  not  omit  to  emphasize  that  anesthesia  possesses  the  double 
value  of  being  a  prophylactic  as  well  as  a  curative  measure  in  inflam- 
mations. This  relatively  novel  method  of  treating  inflamed  tissues 
will  permit  of  still  further  elaboration,  to  the  great  advantage  of  our 
patients  as  well  as  to  our  own.  By  the  extensive  application  of  anes- 
thesia we  approach  very  closely  one  of  our  noblest  aims,  namely,  to 
operate  painlessly  as  well  as  to  render  the  postoperative  treatment  of 
exceedingly  painful  inflammatory  processes  permanently  painless,  at 
the  same  time  hastening  the  repair  of  abnormal  tissue  lesions. 

Prophylactic  Treatment  of  Timid  and  Sensitive  Patients. — Accord- 
ing to  Williger's  experience,  bromural  or  scopolamin-morphin  have 
exhibited  a  very  favorable  action  in  the  prophylactic  treatment  of 
timid  and  sensitive  patients.  The  general  sensibility  is  considerably 
reduced  without  untoward  sequelae.  In  thyroidism,  however,  scopo- 
lamin-morphin is  contraindicated.  Williger  prescribes  these  two  drugs 
as  follows: 

I^ — Scopolaniin  hydrobromid 0.006 

Morphin        . 0.15-^ 

Water 10.00 

M.  D.  S. — From  three  to  six  divisions  of  a  Pravaz  syringe,  according  to  the  patient's  physical 
condition,  to  be  injected  one  hour  before  operation. 

„     -p,  .  f  o .  3  (one  tablet)  for  children 

\o.6  (two  tablets)  for  adults 

M.  D.  S. — To  be  taken  internally  forty-five  minutes  before  operation.     (WiUiger.) 


PART     III 

TECHNIQUE  OF  LOCAL  ANESTHESIA 


ANATOMICAL   STRUCTURE   OF  THE    OSSEOUS   FRAME   OF 
THE    MAXILLA 

The  osseous  frame  of  the  maxillae,  which  is  formed  by  the  maxilla 
and  the  mandible,  possesses  a  number  of  peculiarities  which  are  of 
special  importance  for  the  technique  of  local  anesthesia  and  the  diffu- 
sion of  the  solutions  injected.  The  pressure  exerted  in  injecting  is 
intended  to  force  the  anesthetic  agent  through  the  canaliculi  in  the 
outer  surface  of  the  bone  into  the  interior  of  the  alveolus,  whereby 
the  nerves  supplying  the  teeth  can  be  paralyzed.  It  is  the  purpose  of 
the  following  pages  to  demonstrate  at  which  points  of  the  maxillary 
apparatus  such  areas  of  diffusion  are  constantly  found. 

The  Surfaces  of  the  Maxillae. — If  we  examine  the  jaws  of  a  macerated 
skull,  we  note  that  spongiose,  or  richly  canaliculated  (cancellated) 
osseous  tissue,  alternates  with  cortical  mass  that  presents  but  few 
canaliculi. 

Maxilla. — The  latter  compact  substance  extends  in  the  maxilla 
especially  labially  and  buccally,  but  is  interrupted  in  most  skulls 
by  definite  and  invariably  present  cancellous  areas,  which  are  of  the 
greatest  importance  in  local  anesthesia.  For  only  in  these  areas  is  it 
possible  to  force  the  solution  with  moderate  pressure  and  without 
causing  lesions  through  the  bone  into  the  alveolus,  flooding  and  anes- 
thetizing the  entire,  profusely  innervated  environment  of  the  tooth 
root  (see  Fig.  46). 


104 


TECHNIQUE  OF  LOCAL  ANESTHESL4 


Anterior  Surfaces  of  the  Maxillary  Bones. — In  Figs.  12  to  18 
the  anterior  views  of  several  skulls  of  different  sex  and  age  are  presented 
in  order  to  show  the  various  stages  in  the  development  of  the  sieve- 


FlG.    12 


Pig.  13 


MaxillcB  of  child,  aged  seven,  showing  extensive 
cancellous  areas. 


Maxillae  of  young  person,  showing  extensive 
cancellous  areas. 


Fig.  14 


Fig.  15 


Maxillae  of  young  person,  showing  extensive 
cancellous  areas. 


Maxillae  of  old  person,  showing  few 
perforations. 


like  cancellous,  spongiose  areas,  and  their  varying  extent  in  different 
skulls.  Red  arrows  indicate  specially  pronounced  areas  which  guarantee 
a  good  diffusion  of  the  solution.  Fig.  12  shows  the  skull  of  a  child, 
aged  seven  years,  in  which  the  conditions  are  extremely  favorable  for 


AXATOMICAL  STRUCTfRE  OF  OSSEOUS  FRAME  OF  MAXILL.E      lOo 

diffusion;  Fig.  13,  the  skull  of  a  man,  aged  twenty  years,  in  which  the 
characteristic  cancellous  areas  plainly  appear. 

In  the  maxilla  as  well  as  in  the  mandible  the  alveolar  ridges  at  the 
necks  of  the  teeth  always  exhibit  sieve-like  perforations,  as  does  the 


Fig.  17 


Ma.xilltg  of  old  person,  showing  few  perforations.      Maxillae  of  adult,  showing  numerous  perforations 
Fig.  18  Fig.  19 


Maxillae  of  adult,  showing  numerous  perforations. 


Lateral  view  of  Fig.  12. 


depression  at  the  anterior  nasal  spine,  or  incisive  fossa  in  the  region 
of  the  root  apices  of  the  upper  central  incisors.  In  the  mandible  the 
cancellous  areas  are  otherwise  limited  to  the  anterior  portion  in  the 
region  of  the  chin  (see  Figs.  13  and  18).     Mesially  from  the  root  apex 


106 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


of  the  canine,  in  the  mental  fossa,  groups  of  small  foramina  are  dis- 
tributed which  sometimes  extend  up  to  the  alveolar  ridge  (see  Figs.  12, 
14,  17,  and  18).  Especially  Fig.  18  shows  plainly  how  finely  perforated 
the  mental  portion  may  be.     The  skulls  of  older  persons,  especially  in 


Fig.  20 


Lateral  view  of  Fig.  13. 
Fig.  22 


Lateral  view  of  Fie.  15. 


Lateral  view  of  Fig.  14. 
Fig.  23 


Lateral  view  of  Fig.  16. 


the  mandibular  portions,  show  very  few  perforations  (see  Figs.  15,  16, 
and  17). 

The  lateral  aspect  of  the  same  skulls  shows  that  the  cancellous  areas 
in  the  maxilla  are  fewer  toward  the  molars,  while  in  the  mandible 
they  are  lacking  entirely  (see  Figs.  19  to  25).     In  the  latter  only  the 


ANATOMICAL  STRUCTURE  OF  OSSEOUS  FRAME  OF  MAXILLA     107 

alveolar  ridge  is  perforated,  while  toward  the  base  a  thick  cortical 
layer  prevails.    The  youthful  jaw  (see  Fig.  19)  exhibits  the  widest  extent 


Fig.  24 


Fig.  25 


Extent  of  cancellous  bony  tissue  at  the  maxillary  tuberosity.   Above  the  empty  alveolus  of  the  third 
molar  large  foramina  are  seen,  by  which  the  posterior  superior  dental  nerves  enter  the  maxilla. 

of  cancellous  area,  even  the  mandible  being  traversed  by  canaliculi. 
Fig.  20  gives  a  good  view  of  the  cancellous  fossa  at  the  level  of  the 


108 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


root  of  the  upper  canine,  this  fossa  in  all  skulls  being  more  or  less  pro- 
nouncedly canaliculated.  The  middle  root  portion  in  these  teeth, 
however,  is  often  covered  by  a  dense  cortical  layer  (see  Figs.  21  to  23). 
The  character  of  the  osseous  tissue  above  the  upper  bicuspids  is 
of  great  interest.  It  is  especially  closely  perforated,  generally  to  the 
entire  extent  from  the  alveolar  ridge  to  the  root  apex  (see  Figs.  20 
and  21). 

Fig.  27 


Median  palatine 
suture 


Palatine  spine 


Posterior  palatine 
foramen 


Transi-erse  palatine  /  I'osterior  nasal  spine 

suture  Portion  of  horrMnial  plate 

of  palate  bone 

View  of  palatal  surface  of  maxilla. 

The  upper  molars  are  covered  by  an  osseous  plate  of  chiefly  cortical 
character,  which  over  the  third  molars  usually  is  again  closely  per- 
forated, as  a  glance  at  the  tuberosity  in  Fig.  26  plainly  shows. 

Foramina  in  the  Anterior  Surface. — The  anterior  surfaces  of  the 
maxillary  bones  present  two    very   important    large    foramina  which 


ANATOMICAL  STRUCTURE  OF  OSSEOUS  FRAME  OF  MAXILL.-E     109 

permit  the  passage  of  important  nerves  and  vessels,  namely,  in  the  maxilla 
the  infra-orbital  foramen  above  the  root  of  the  first  bicuspid,  in  the 
mandible  the  mental  foramen  below  and  between  the  first  and  second 
bicuspids. 

Fig.  28  Fig.  29 


Palatal  surface  of  maxilla  of  youthful  person, 
showing  extensive  cancellous  areas. 


Palatal  surface  of  maxiUa  of  youthful  person 
showing  extensive  cancellous  areas. 


Fig.  30 


Fig.  31 


Palatal  surface  of  maxilla  of  adult,  showing 
few  perforations. 


Palatal  surface  of  maxilla  of  old  person,  showing 
few  perforations. 


The  Posterior  Surfaces  of  the  Maxillary  Bones. — Maxilla. — 
Palatal  Surface  of  the  Maxilla. — The  posterior  surface  of  the  ma.xilla 
is  traversed  by  numerous  canals  which  are  distributed  very  regularly. 
Fig.  27  shows  the  palatal  view  of  the  maxilla,  the  hard  palate  in  its 


no 


TECHNIQUE  OF  LOCAL  ANESTLIESIA 


anterior  and  median  portions  being  greatly  perforated.  At  the  bi- 
cuspids the  cancellous  arrangement  of  the  alveolar  bone  decreases  at 
the  middle  portion  of  the  root,  and  gradually  disappears  toward  the 
molars.     Here  we  find  the  large  posterior  palatine  foramen. 

Hence  it  appears  that  the  molars  are  covered  also  palatally  with  a 
relatively  dense  mass  of  bone,  while  the  osseous  cover  of  the  bicuspids 
above  the  root  apices  possesses  fine  foramina,  and  the  incisors  and 
canines  are  surrounded  on  all  sides  with  cancellated  bony  tissue.  This 
is  shown  equally  clearly  in  Figs.  28  to  31.  These  illustrations  further- 
more disclose  the  fact  that  the  cancellous  areas  in  the  palatal  surface 
vary  in  different  individuals.  Figs.  28  and  29  represent  greatly  per- 
forated youthful  skulls;  Figs.  30  and  31,  considerably  less  cancellated 
maxillae  of  older  subjects. 


Fig.  32 


Fig.  33 


Inner  surface  of  mandible,  showing  dense  bone. 


Foramina  are  noted  at  the  symphysis. 


Foramina  in  the  Palatal  Surface. — In  the  palatal  surface  of  the  maxilla 
we  find  two  well-marked,  large  foramina,  the  incisive  or  anterior  palatine 
foramen  behind  the  central  incisors  and  the  posterior  palatal  foramina 
at  the  level  of  the  third  molars,  as  clearly  illustrated  in  Fig.  27  (see 
also  Figs.  28  to  31). 

Mandible.  —  Timer  Surface  of  the  Mandible. — The  inner  surface 
of  the  mandible,  in  contradistinction  to  the  maxilla,  is  entirely 
non-canaliculated.     Only  at  the  internal  geyiial  tubercles,  some  partly 


THE  INFERIOR  DENTAL  OR  MANDIBULAR   FORAMEN  111 

fair-sized  foramina  are  noted  which  frequently  reach  to  the  alveolar 
ridge,  and  in  transverse  sections  are  seen  to  communicate  with  the 
mandibular  canal  (see  Fig.  34,  also  Figs.  32  and  33),  while  the  entire 
posterior  portion  up  to  the  third  molars  is  almost  impenetrable 
and  non-canalicular  (see  Fig.  35).  At  the  angle  of  the  jaw,  however, 
in  the  ascending  ramus  we  find  a  very  large  aperture,  namely,  the 
mandibular,  oblique,  or  inferior  dental  foramen  (see  Figs.  35  to  37, 
and  60),  which  is  important  for  local  anesthesia  of  the  mandible. 

Fig.  34 


Section  through  symphysis  of  mandible.     Some  of  the  foramina  on  the  inner  surface  communicate 
with  the  inferior  dental  canal,  fibers  of  the  lingual  nerve  probably  joining  the  inferior  dental  nerve. 


THE  INFERIOR   DENTAL   OR   MANDIBULAR  FORAMEN 

In  adults  the  ascending  ramus  begins  a  little  behind  the  third  molar, 
sometimes  in  an  abruptly  ascending  surface.  At  its  basis,  which  must 
be  regarded  as  resting  upon  the  alveolar  process,  the  ascending  ramus, 
in  front  view,  shows  an  outer  buccal  anterior  ridge,  representing  the 
last  ascending  portion  of  the  external  oblique  line  (see  Figs.  35  to  39). 
About  0.5  cm.  inward  and  backward  of  this  line  runs  a  ridge  bordering 
the  lingual  surface,  the  internal  oblique  line,  which  gradually  loses 
itself  in  the  posterior  section  of  the  coronoid  process.  Between  these 
two  lines  in  the  bony  surface  is  situated  a  more  or  less  pronounced, 
deep  groove,  which  we  might  call  the  retromolar  fossa  (see  Figs.  36, 
38,  and  39).  Above  this  fossa  the  mucosa  is  slightly  depressed  in 
what  might  be  called   the  retromolar  triangle.     About  the  middle  of 


112 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


the  internal  surface  portion  of  the  ascending  ramus  the  large  inferior 
dental  or  mandibular  foramen  is  situated,  extending  downward  and  for- 
ward (see  Figs.  35  to  37,  and  39),  at  the  same  time  marking  the  termina- 
tion of  the  mylohyoid  groove  which  ascends  from  below  anteriorly  to 
above  posteriorly  (see  Figs.  35,  37,  and  39).  The  orifice  of  the  foramen 
itself  is  more  or  less  protected  anteriorly  by  a  spiculum  of  bone  of  vary- 
ing size,  the  mandibular  lingula  (see  Figs.  35,  37,  and  39).  This  lingula 
may  be  developed  as  a  pointed  plate  of  bone,  or  as  a  tongue-like  cover, 


Fig.  35 


S;(/»(t  id  notch 

Pte)  i/qoid  depression 
\  Condyloid  procesa 


Mi/io-hyoid 
Intenial  (jenial        ridge 
tubercles 

Side  view  of  inner  surface  of  right  half  of  mandible.  The  red  arrow  indicates  the  direction  in 
which  the  needle  should  be  pushed  forward  over  the  lingula.  The  red  circle  indicates  the  area 
of  injection. 

or  only  as  a  thickened  process  on  the  anterior  margin  (see  Fig.  37). 
Sometimes  the  lingula  is  connected  with  the  lower  free  margin  of  the 
orifice  of  the  foramen  by  a  small  spiculum  or  bridge. 

The  foramen  itself,  in  adults,  is  always  situated  above  the  alveolar 
ridge  and  in  a  horizontal  plane  about  1.5  cm.  from  the  anterior  ridge 
of  the  jaw  (the  external  oblique  line)  (see  Figs.  37,  C,  and  39).  The  two 
halves  of  the  mandible,  when  viewed  from  in  front,  gradually  diverge 
toward   the   angle,   so   that  the  inner  surface  of   the   angle  with  the 


THE  INFERIOR  DENTAL  OR   MANDIBULAR   FORAMEN 


11:5 


mandibular  foramen  is  inclined  posteriorh'  and  phai'\-ngeally,  and 
appears  to  be  entire!}'  covered  by  the  internal  ol)lique  line  (see  Figs. 
36,  37,  83,  and  88). 

Fig.  36 


CmulyluUI  pioc 


^Coronoid  process 


Inteiniil  oblique 
line 

_   Exfenial  olilique 


InteiiKtl  oblique 
line 


-Mental  foramen 


Relationship  of  the  ascending  ramus  to  the  body  of  the  jaw.    The  red  arrow  indicates  the  direction 
in  which  the  syringe  should  be  advanced  to  the  inferior  dental  foramen. 

In  iiiaiidibiilar  anesthesia  the  insertion  of  the  needle  is  to  be  made 
closely  above  the  lingula,   and   the  solution  is  to  be  deposited   in   the 


114 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


Fig.  37 
Coroiioid  procesx^^j/^   LAngula 


—  Condyloid  process 


Inferior  dental 

foramen 


Anqie 
Mylo-kyoid  groove 
<  Submaxillary  fossa 

Mylo-hyoid  ridge 

Variations  of  the  inferior  dental  foramen  at  different  ages:  A,  mandible  of  a  child,  aged  seven 
years  (the  needle  should  be  inclined  slightly  downward).  B,  mandible  of  a  youth,  aged  eighteen 
years.  C,  mandible  of  a  male  adult,  aged  thirty  years.  The  red  arrows  indicate  the  direction 
of  the  needle. 


THE  INFERIOR  DENTAL  OR   MANDIBULAR   FORAMEN 


115 


neighborhood  of  the  nerve  trunk  that  enters  there  (see  Figs.  38,  39, 
and  97;  note  the  red  arrows  in  Figs.  35  to  37). 


Fig.  38 


Front  view  of  position  of  syringe  in  mandibular  anesthesia:  l,  internal  oblique  line;   2,  external 
oblique  line;  3,  insertion  of  needle  about  l  cm.  above  masticating  surfaces  of  molars. 


Fig.  39 


Position  of  needle  in  mandibular  anesthesia:  I,  external  oblique  line;  2,  internal  oblique  line; 
3,  position  of  needle  at  superior  margin  of  lingula;  4,  most  suitable  length  of  needle  behind  lingula 
(a  further  advancement  would  result  in  failure) ;  6,  position  of  needle,  I  cm.  above  level  of  masticating 
surfaces  of  molars;  7,  lingula;  8,  inferior  dental  foramen. 


116  TECHNIQUE  OF  LOCAL  ANESTHESIA 

THE    MINUTE  STRUCTURE   OF  THE  ALVEOLAR  PROCESS 

Structure  of  the  Osseous  Substance. —  In  ground  sections  of  the 
alveolar  processes  of  either  jaw  two  different  layers  of  osseous  tissue 
are  continually  found,  namely,  the  sparingly  canaliculated  substance, 
the  compact  substance,  and  the  richly  cancellous  and  medullated  tissue, 

Fig.  40 
Spongiose  alveolar  margin 


Extent  of  spongiose   (cancellous)  substance  within  an  exposed  alveolus. 

the  spongiose  substance.  The  former  in  the  mandible  shows  a  solidly 
arranged  periphery,  its  thickness  varying  with  age  and  with  the  long- 
diameter  of  the  bone.  The  spongiose  substance  which  occupies  the 
interior  of  this  solid  cortical  capsule  resembles  a  sponge  in  the  arrange- 


EXPLANATION  OF  ABBREVIATIONS  ON  FIG.  41 

2S,  lower  left  second  bicuspid;  iB,  lower  left  first  bicuspid;  jC,  lower  left  canine;  2/.  lower  left 
lateral  incisor;  iZ,  lower  left  central  incisor;  Ji,  lower  right  central  incisor;  /j,  lower  right  lateral 
incisor;  Ci,  lower  right  canine;  If.  F.,  mental  foramen:  C.  m.,  mandibular  canal;  7^.  C. ,  facial  cortical 
layer;  L.L.,  lingual  cortical  layer;  pal.  Corl.,  palatal  cortical  layer;  E.S.,  extraction  scar;  C':  upper 
right  canine;  /-,  upper  right  lateral  incisor;  /',  upper  right  central  incisor;  B^,  upper  right  second 
bicuspid;  Spong.,  spongiose  (cancellous)  bone;  Cort.,  cortical  layer;  M2,  lower  right  second  molar; 
M3,  lower  right  third  molar;  B^.  upper  right  first  bicuspid;  M',  upper  right  second  molar;  M^,  upper 
right  third  molar;  Af' ,  upper  right  first  molar;  Cort.  pal.,  palatal  cortical  layer;  Tuber,  max.,  maxil- 
lary tuberosity. 


Fig.  41 


^  iVii'-i^-  Spong, 


^■y,y^  -s.         y         Alveolus  Alveolar  margin 

^•«vGR  :'■--■      V*.-^  ofjB'      ;  Septum 

\r*'iV'>S6.^'    V  PalCort.  i-i-      ■';   Alveolar  base 

c   I-       -T   ''.*?    Tuber]  ,  '-  i»  *       riT'i  ,    ^     . 

^■^■''  \       ■■5L   max.   Sponq.y^f  ■^  4  q  I        .pal-Corl. 

pal.  Cort.. 
Spong. 


Nasal  wall 

/    " 
F.  C.       9 

Horizontal  and  vertical  sections  of  the  alveolar  process  in  the  maxilla  and  mandible. 


118  TECHNIQUE  OF  LOCAL  ANESTHESIA 

ment  of  the  individual  lamellse  and  rods.  These  osseous  rods  are  gener- 
ally so  arranged  in  regard  to  direction  as  to  radiate  from  the  cortical 
layer  (see  Figs.  44,  Nos.  i  to  21). 

Toldt  attributes  this  architecture  of  bone  partly  to  an  intracar- 
tilaginous  ossification,  partly  to  the  normal  developmental  processes 
(apposition  and  resorption)  of  the  surrounding  compact  layer.  With 
advancing  age  the  spongiose  meduUated  spaces  increase,  while  the 
osseous  supports  of  the  teeth  decrease,  so  that  the  compact  substance 
gradually  closes  in  upon  a  space  of  little  internal  resistance. 

Structure  of  the  Alveoli.  —  The  dental  alveolus  may  be  regarded 
as  a  crater-shaped  depression  in  the  spongiose  substance  consisting 
of  highly  porous  osseous  tissue,  in  which  the  root  is  contained  (see. 
Fig.  41,  No.  19;  Fig.  44,  Nos.  17  and  19).  The  individual  alveoli  are 
separated  by  septa,  consisting  of  thin  and  porous  lamellae  from  two 
approximating  alveoli  and  of  spongiose  tissue  developed  between  the 
latter  (see  Figs.  41,  42,  and  44).  The  alveoli  of  the  upper,  especially 
the  first  bicuspids,  also  those  of  the  lower  bicuspids  in  their  fundus 
contain  ridge-like  eminences,  septal  processes,  which  fit  in  the  longi- 
tudinal depressions  in  the  roots  of  these  teeth.  The  alveolar  walls 
always  exhibit  fine,  sieve-like  (cribriform)  perforations,  which  increase 
in  number  and  diameter  toward  the  upper  margin  (see  Figs.  41,  42, 
and  44). 

These  perforations,  which  are  always  present  in  varying  numbers 
in  the  alveolar  ridge,  and  seem  to  permit  of  ready  diffusion  of  the 
anesthetizing  fluid,  have  heretofore  been  unduly  neglected,  inasmuch 
as  they  furnish  us  with  valuable  landmarks  in  the  technique  of  local 
injection  anesthesia. 

Transverse  Sections  of  the  Jaws. — Fig.  41,  Nos.  i  to  20,  shows  a 
number  of  instructive  bone  sections,  in  which  the  various  relations 
of  the  dental  roots  to  their  alveoli,  and  the  structure  of  the  body  of 
the  jaws  themselves  can  be  studied.  Nos.  i  to  5  exhibit  lamellar 
portions  of  the  anterior  section  of  the  mandible  from  the  left  second 
bicuspid  to  the  right  canine. 

Maxilla  and  Mandible. — Besides  the  instructive  transverse  sections 
of  the  roots,  we  can  trace  in  No.  2  the  gradually  increasing  thickness 


THE  MINUTE  STRUCTURE  OF  THE  ALVEOLAR  PROCESS  119 

of  the  outer  and  inner  cortical  layers,  and  the  manner  in  which,  be- 
tween them,  the  spongiose  layers  are  arranged  around  the  bodies  of 
the  roots.  In  No.  4  only  the  apical  portions  of  the  long  roots  of  the 
canines  can  be  recognized,  while  in  No.  5  the  widely  cancellated  tissue 
appears  in  the  proximity  of  the  mandibular  canal,  which,  on  the  left, 
communicates  through  the  exposed  mental  foramen  with  the  anterior 
surface.  While  most  roots  are  surrounded  with  spongiose  substance, 
the  roots  of  the  canines  are  gripped  by  the  cortical  layer,  which  here 
appears  to  extend  remarkably,  this  condition  contributing  largely  to 
the  firmness  of  the  supporting  abutments  of  the  denture,  namely  the 
canines. 

Fig.  42 


Zygomatic  process^ 

Infra-orbital  foramen^ 
Alveolar  septa^^^ 


Palatal  surface     Compact  bone  1 
Anterior  palatine  foramen 

View  of  cancellous  alveolar  margin  of  maxilla.   The  alveolar  septa  and  margins  are  greatly  cancellated. 

The  same  condition  is  plainly  shown  in  Fig.  41,  No.  7,  which,  like 
Nos.  8,  9,  15,  and  16,  illustrates  additionally  the  organization  of  an 
old  extraction  wound  into  spongiose  substance  (see  Nos.  8  and  9, 
between  C  i  and  B2,  Nos.  15  and  16,  between  B2  and  M  i).  Nos.  14 
to  18  represent  the  structural  details  of  one  maxillary  half,  showing 
that  the  cortical  layers  are  here  of  a  considerablj'  more  delicate  devel- 
opment than  in  the  mandible.  Moreover  the  palatine  cortical  layer  is 
seen  to  be  canaliculated.  In  No.  19  it  is  further  seen  that  the  cortical 
layers  covering  the  posterior  buccal  and  palatal  surfaces  of  the  maxilla 
may  increase  or  decrease  in  thickness  in  inverse  proportion.     While 


Fig.  43 


Vertical  sections  through  the  alveolar  process  of  the  maxilla.  Left  side,  the  facial  external;  right 
side,  the  palatal,  internal  surface;  i  to  4,  incisors;  5  and  6.  canine:  7  to  10,  bicuspids;  11  to  16. 
molars. 


Fig.  44 


Vertical  sections  through  the  alveolar  process.  Left  side,  the  lingual  internal  of  mandible;  right 
side,  the  facial,  external  surface:  I  to  4,  incisors  and  canines;  5  to  9,  bicuspids;  10  to  16,  molars; 
17  to  21,  alveoH  of  molars  from  another  skull. 


122 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


the  buccal  surface  starting  from  the  alveolar  margin  often  increases 
from  a  delicate  stratum  to  a  thick  cortical  layer,  the  palatine  covering 
is  rather  thick  at  the  alveolar  margin,  whence  it  gradually  tapers. 
Fig.  42  shows  the  open  alveoli  of  an  upper  first  molar,  this  illustration 
again  emphasizing  the  fact  that  the  most  favorable  conditions  for 
diffusion  exist  at  the  alveolar  margin. 


Fig.  45 


/■ 


Bloodvessels  (blue)  and  lymph  vessels  (red)  in  spongiose  substance  of  maxiUas. 


Sections  of  the  Maxilla  and  Mandible. — In  order  still  further  to 
elucidate  the  conditions  for  diffusion  in  the  maxillary  bones,  the  writer 
has  made  special  vertical  sections  of  the  maxilla  and  the  mandible, 
as  shown  in  Figs.  43  and  44. 

Maxilla. — In  Figs.  43,  Nos.  l  to  16,  the  relations  of  the  upper  teeth 
to  the  alveolar  process  are  illustrated.  The  left  side  of  each  of  these 
sections    represents   the    facial,  the   right,  the  palatal   surface.     Nos. 


THE   MINUTE  STRUCTURE  OF  THE  ALVEOLAR  PROCESS 


123 


I  to  6  show  the  anterior  teeth  including  the  canine;  Nos.  7  to  10, 
the  bicuspids;  Nos.  11  to  16,  the  molars.  All  these  illustrations  on  the 
palatal  surface  present  a  broad  osseous  layer,  which  varies  on  the 
facial   surface.      It  is  delicate  and   lamellar  for  the  greater  part,  and 

Fig.  46 


Diffusion  of  injected  staining  solution  (red)  within  the  bony  alveolar  process. 

up  to  the  bicuspids  specially  thin  in  the  proximity  of  the  root  apices, 
i.  e.,  in  the  area  which  is  generally  richly  cancellated.  It  is  here,  there- 
fore, that  the  best  possible  diffusion  can  be  obtained.  The  roots  of 
the  molars  frequently  are  covered  with  but  a  thin  lamella,  which  is. 


124 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


however,  almost  non-canaliculated,  and  increases  in  tliickness  at  the 
third  molar.  This  tooth,  by  way  of  compensation,  in  the  region  of 
its  root  apices  is  surrounded  by  richly  cancellated  tissue,  so  that  it 
can  be  perfectly  well  anesthetized  by  inserting  the  needle  high  up 
(see  Fig.  93). 

Fig.  47 


Appearance  of  red  stain  particles  within  the  pulp  capillaries  (vessels  blue). 

Mandible. — The  sections  through  the  mandible  plainly  show  the 
massive  nature  of  the  cortical  layer  on  both  sides  (see  Fig.  44).  While 
in  the  anterior  teeth  the  facial  surface  of  the  bone  (on  the  right  in 
the  illustrations)  is  of  relatively  thin  construction,  its  thickness  in- 
creases considerably  from  the  bicuspids  on,  and  finally  reaches  at  the 
molars  (Nos.  10  to  16),  the  same  proportions  as  the  lingual  surface. 
If  in  the  mandible  local  anesthesia  by  way  of  the  mucosa  is  of  any 
value  at  all,  it  can  be  effected  only  by  injection  at  the  cervical  margin 
of  the  gum,  the  alveolar  ridges  in  all  lower  teeth  being  of  spongiose 


THE  NERVE  SUPPLY  OF  THE  ,  MASTl  CATORY  APPARATUS  125 

character.  This  fine,  spongiose,  cancellous  tissue  of  the  alveoli,  even 
in  the  molars,  is  present,  however,  only  in  the  upper  marginal  portion, 
as  illustrated  in  Fig.  44,  Nos.  17  to  21,  also  in  Fig.  41,  and  in  Fig.  84. 

The  foregoing  renders  it  sufficiently  apparent  that  the  technique 
of  local  injection  anesthesia  depends  not  only  upon  the  nerve  supply 
of  the  masticator}'  apparatus,  but  also,  and  to  a  great  extent,  upon 
the  special  character  of  the  bony  substance.  We  shall  have  occasion 
to  prove  that  the  technique  of  local  anesthesia  as  demonstrated  sub- 
sequently is  based  on  these  anatomic  principles,  and  for  that  very 
reason  guarantees  such  a  high  degree  of  perfection  and  safety'. 

Details  of  Diffusion. — In  order  to  establish  the  velocity  and  the 
manner  of  diffusion  of  injected  solutions  in  the  jaws,  the  writer  has 
injected  the  periosteum  of  the  maxilla  and  the  mandible  in  various 
animals,  such  as  cats,  with  isotonic  staining  solutions  in  the  same 
manner  as  for  the  purpose  of  local  anesthesia.  In  all  cases  the  can- 
cellated mass  was  permeated,  and,  where  cortical  substance  was 
present,  the  red  carmine  solution  penetrated  by  way  of  the  foramina 
(see  Fig.  45).  Spongiose  cancellous  bone  tissue  absorbs  the  stain  with 
uniform  avidity,  permitting  it  to  penetrate  into  the  medullary  spaces. 
After  five  minutes,  in  most  cases,  the  anterior  of  the  jaw  was  entirely 
permeated  with  the  colored  solution;  up  to  the  pulp  within  from  six 
to  eight  minutes.  The  capillaries  of  the  pulp  at  the  odontoblastic 
layer  are  seen  to  be  filled  with  particles  of  stain  (see  Fig.  47),  while 
within  the  osseous  canaliculi  red-stained  lymph  vessels  are  found 
chiefly  in  perivascular  arrangement  (see  Fig.  45).  This  is  conclusive 
proof  that  an  isotonic  injecting  solution,  such  as  the  novocain-thymol 
solution,  reaches  the  interior  of  the  alveolar  process  in  a  short  time, 
most  rapidh"  and  to  the  greatest  extent  in  spongiose  substance,  in  the 
cortical  areas,  however,  only  by  way  of  the  few  and  generally  large 
foramina. 

THE  NERVE  SUPPLY  OF  THE  MASTICATORY  APPARATUS 

The  sensibility  of  the  masticatory  apparatus  is  controlled  by  the 
fifth  cranial  nerve,  the  trigeminal. 


126  TECHNIQUE  OF  LOCAL  ANESTHESIA 

Root  of  the  Trigeminal  Nerve. — The  trigeminal  nerve  arises  by  a 
ventral,  smaller,  motor  root,  and  a  dorsal,  larger,  sensory  root  at  the 
pons  Varolii,  and  extends  anteriorly  to  the  apex  of  the  petrous  portion 
of  the  temporal  bone  (see  Fig.  48).  Here  the  sensory  root  forms  the 
large  semilunar  or  Gasserian  ganglion,  from  which  proceed  the  three 
main  branches,  the  ophthalmic,  the  maxillary,  and  the  mandibular 
(see  Fig.  49).  The  motor  root  passes  beneath  the  ganglion  Avithout 
having  any  connection  with  it,  to  the  third  division,  which  thereby,  as 
a  mixed  nerve  consisting  of  sensory  and  motor  fibers,  is  distinguished 
from  the  exclusively  sensory  first  and  second  divisions. 

The  Ophthalmic  Nerve. — The  ophthalmic  nerve,  or  first  division  of 
the  trigeminal,  passes  from  the  Gasserian  ganglion  through  the  lateral 
wall  of  the  cavernous  sinus  to  the  superior  orbital  or  sphenoidal  fissure, 
and  through  this  to  the  orbit.  To  the  first  division  of  the  trigeminal 
nerve  belongs  the  ciliary  ganglion,  situated  in  the  posterior  third  of 
the  orbit  laterally  to  the  optic  nerve  (the  second  cranial  nerve),  and 
possessing  three  roots,  one  short  motor  root  (radix  brevis),  one  long 
sensory  root  (radix  longa),  and  one  sympathetic  root  (radix  sympathetica) 
(see  Fig.  48). 

Branches  of  Distribution  of  the  First  Division  of  the  Trigeminal 
Nerve. — The  lacrimal  nerve,  which  belongs  to  the  first  division,  passes 
forward  along  the  lateral  wall  of  the  orbit  above  the  lateral  rectus 
muscle,  and  supplies  the  lacrimal  gland,  as  well  as  the  distal  corner  of 
the  eye  and  the  conjunctiva.  The  frontal  nerve  enters  the  orbit  above 
the  muscles  through  the  sphenoidal  fissure,  and  runs  forward  along 
the  middle  line,  between  the  levator  palpebrae  and  the  periosteum, 
giving  off  through  the  supra-orbital  foramen  the  supra-orbital  nerve, 
and  as  a  second  branch  the  supratrochlear  nerve  above  the  trochlea  or 
pulley  of  the  superior  oblique  muscle,  supplying  the  eyelids,  the  integ- 
ument of  the  lower  part  of  the  forehead  on  either  side  of  the  middle 
line,  and  the  root  of  the  nose.  The  nasal  nerve  enters  the  orbit  by 
way  of  the  sphenoidal  fissure  between  the  two  heads  of  the  external 
rectus,  spreading  here  between  the  oculomotor  and  the  external  or 
abducent  oculomotor  nerves.  It  passes  obliquely  inward  across  the  upper 
portion  of  the  optic  nerve,  sending  a  long  root  to  the  ciliary  ganglion, 


:c    :=  .55 


i/m 


•   8=../  ▼    \  f   _  -/■  §  c    =? 


128  TECHNIQUE  OF  LOCAL  ANESTHESIA 

and  giving  off  the  long  ciliary  nerves,  which,  arranged  around  the  optic 
nerve  together  with  the  short  ciliary  nerves  from  the  cihary  ganghon  in 
the  orbital  adipose  tissue,  run  forward  and  enter  through  the  sclera  near 
the  entrance  of  the  optic  nerves.  The  continuation  of  the  nasal  nerve 
runs  to  the  median  wall  of  the  orbit,  giving  off  the  spheno-ethmoidal 
nerve  to  the  cribriform  plate  of  the  ethmoid  bone,  also  the  infratrochlear 
nerve  to  the  integument  at  the  mesial  corner  of  the  eye,  the  lacrimal 
sac,  and  the  eyelids  (see  Fig.  48). 

The  Maxillary  Nerve. — The  second  or  maxillary  division  of  the 
trigeminal  passes  from  the  Gasserian  ganglion  through  the  foramen 
rotundum  to  the  sphenomaxillary  fossa,  after  giving  off  the  meningeal 
branch  to  the  dura  mater.  At  the  sphenomaxillary  fossa  the  second 
branch  is  divided  into  the  following  subdivisions:  The  orbital  or  tem- 
poromalar  branch,  the  infra-orbital  branch,  with  the  posterior,  middle, 
and  anterior  superior  dental  branches,  and  the  sphenopalatine  branches 
(see  Figs.  48,  49,  51,  and  52). 

Close  to  the  sphenopalatine  foramen  lies  the  sphenopalatine  or 
Meckel's  ganglion,  consisting  of  sensory  (the  sphenopalatine  branches) , 
motor,  and  sympathetic  roots  (the  Vidian  nerve).  From  the  ganglion 
the  sensory  nasal  branches  pass  to  the  nasal  cavity,  one  branch,  the 
nasopalatine  nerve,  running  to  the  anterior  palatine  canal.  The  palatine 
nerves  pass  through  the  pterygopalatine  canal  to  the  oral  cavity, 
where  they  break  up  into  the  anterior,  middle,  and  posterior  palatine 
nerves.  They  supply  the  mucous  membrane  of  the  palate  with  sensory 
and  the  palatine  muscles,  excepting  the  tensor  palati  muscle,  with 
motor  filaments  (see  Figs.  48,  50,  and  52). 

Branches  of  Distribution  of  the  Maxillary  Nerve. — The  second 
division  of  the  trigeminal  passes  through  the  infra-orbital  canal  to 
the  infra-orbital  region  of  the  facial  surface  of  the  maxilla,  giving  off 
numerous  branches  in  its  course  (see  Figs.  48,  51,  and  52).  In  passing 
through  the  infra-orbital  canal  it  gives  off  the  superior  dental  branches 
at  various  intervals  through  the  minute  canals  into  the  body  of 
the  maxilla  (see  Figs.  48,  49,  and  52).  These  posterior,  middle,  and 
anterior  superior  dental  branches  supply  the  alveolar  process,  sending 
off  small  twigs  to  the  teeth.     At  the  sphenopalatine  (Meckel's)  ganglion 


130  TECHNIQUE  OF  LOCAL  ANESTHESIA 

the  maxillary  nerve  gives  off  several  branches,  which  partly  follow  the 
arteries,  partly  pass  through  their  own  foramina  into  the  maxillary 
tuberosity  (Figs.  48,  51,  and  52)  and  the  body  of  the  maxilla.  Fol- 
lowing the  arteries,  they  pass  forward  above  the  molars,  branching 
out  within  the  facial  maxillary  wall,  and  finally  communicate  with 
the  anterior  superior  dental  nerves.  They  supply  the  oral  mucosa,  the 
molars,  the  mucous  membrane  of  the  maxillary  sinus,  the  periosteum,, 
and  the  pericementum  (see  Figs.  51  and  52). 

The  Infra-orbital  Branch. — The  infra-orbital  branch  frequently 
divides  into  from  two  to  four  branches,  which  arise  closely  together 
from  the  infra-orbital  foramen  (see  Fig.  51).  They  run  in  a  curve 
from  behind  and  above  downward  to  forward  and  inward.  The 
numerous  branches  that  pass  off  form  a  thick  nerve  plexus,  which 
in  turn  sends  off  finer  branches  to  the  palatine  mucosa,  the  floor  of 
the  nasal  cavity,  the  incisors  and  canines,  the  oral  mucosa,  and  the 
spongiose  substance  (see  Fig.  51).  Above  the  root  of  the  canine  this 
plexus  unravels  itself  into  separate  branches,  which  give  off  delicate 
tendrils  downward  to  the  anterior  and  bicuspid  teeth  (see  Figs.  48, 
49,  and  52). 

From  within  the  alveolar  process  the  thicker  nerve  trunks  send  off 
branches  to  the  teeth  and  the  oral  mucosa  (see  Figs.  48  and  52). 

The  Mandibular  Nerve. — The  third  or  mandibular  division  of  the 
trigeminal  makes  its  exit  from  the  skull  through  the  foramen  ovale, 
dividing  into  a  superior,  chiefly  motor  root,  and  an  inferior,  chiefly 
sensory  root.  Through  the  foramen  spinosum  the  mandibular  nerve 
gives  off  the  recurrent  or  meningeal  branch  to  the  dura  mater  (see 
Fig.  49). 

From  the  superior  motor  root  the  masticatory  muscles  are  supplied 
by  the  following  branches:  The  masseteric,  the  internal  and  external 
pterygoid,  the  deep  temporal,  and  the  buccinator  branches. 

From  the  inferior  root  the  inferior  dental,  the  lingual,  and  the 
auriculotemporal  branches  are  given  off  (see  Figs.  49  and  50). 

The  inferior  dental  nerve,  before  passing  into  the  mandibular  or 
inferior  dental  canal,  gives  off  a  motor  branch,  the  mylohyoid  yierve, 
and  through  the  mental  foramen  a  sensory  branch,  the  mental  nerve 
(see  Figs.  49  and  50). 


132 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


The  lingual  nerve  supplies  the  tongue  and  the  floor  of  the  oral  cavity 
with  sensory  filaments  (see  Figs.  50  and  53).  From  the  chorda  tympani 
nerve,  which  is  a  branch  of  the  facial  nerve  (the  seventh),  it  receives 
secretory  filaments  which  it  conveys  to  the  large  mandibular  glands. 
Besides,  the  chorda  tympani  nerve  receives  filaments  from  the  glosso- 
pharyngeal nerve  (the  ninth)  by  anastomosis  of  the  facial  with  the 
glossopharyngeal  nerve  in  the  tympanic  cavity,  or  through  the  nervus 
intermedins,  which  is  supposed  to  come  from  the  glossopharyngeal 
nucleus  and  to  pass  into  the  chorda  (see  Fig.  52). 


[  7»». 


Auastomobis 
with  01  h 
tal  A/ 
Zygomatico  fa 
cial  {majai } 
branch 
Anterior  teimi- 
nal   branches 
of  infra-orbi- 
tal N. 


Fig.  51 

Zyqomatico  tempoial  blanch 

Oi  bital  (tempoi  o  inalai )  bi  anch 
Tart  imal  N 

t  io>  mtnillai  ?/  N 


Facial  N. 
•eat  superficial 
petrosal  N. 

Deep  petrosal  N. 


Vidian  iV 
Splieno-pahiti lie  ganglion 

Postei  101  siipei  toi  dental 
blanches 


Buccal  branch  of  facial  N. 


Distribution  of  superior  maxillary  nerve.  (Hirschfeld  and  Leveille.)  The  outer  wall  of  the  left 
orbit  is  removed,  also  most  of  the  soft  tissues  in  the  vicinity  of  the  maxilla.  (From  Rauber  and 
Kopsch.) 


To  the  third  division  of  the  trigeminal  belongs  also  the  otic  ganglion 
(Fig.  49),  which  is  situated  immediately  below  the  foramen  ovale. 
The  small  superficial  petrosal  nerve,  continued  from  the  tympanic  plexus, 
conveys  to  the  ganglion  secretory  and  sympathetic  filaments.  The 
secretory  filaments  come  from  the  glossopharyngeal,  the  sympathetic 
ones  from  the  sympathetic  plexus  of  the  internal  carotid  artery, 
whence,  through  the  caroticotympanic  branches,  thej-  communicate  in 
the  tympanic  cavity  with  the  small  superficial  petrosal  nerve. 


'A'  PHVO  uim  -SF  imi1-'o-"-')"i  ^ 

■^\r  9UfjV2V((-OU3l{(IS 


■X  ■)!l<>0 

■y  M2nq;pi(Vjt     ' 
•j^  2DS0jpd  (faaff 
)00.i  .h;;ot«S 


■j\r  ivuutuBux  {' 


snx91'i  pi)0.im  rou-mv 
•jlf  nmduMi  josmx 

■^  josoMSd  ivpif.adm  2!««»S  -  ' 
■  „«•  oiiwdturu  pim  2t>so.ipd  ; 

■vrrDSO.ii3d2moif.isdmiv9JB_,^       X 

'       '  •         ,u)i2euv6S7V2noiU30 

■y  )OT3iy 


•jf  smjadnig 


1--Z^ 


og 


134  TECHNIQUE  OF  LOCAL  ANESTHESIA 

The  sensory  root  of  the  ganglion  communicates  with  the  trigeminal 
through  filaments  from  the  internal  pterygoid  nerve. 

The  otic  ganglion  also  sends  motor  filaments  to  the  tensor  palati 
and  the  tensor  tympani  muscles,  secretory  filaments  to  the  carotid 
artery. 

The  Mandibular  Nerve  with  the  Inferior  Dental  Nerve. — The  largest 
branch  of  the  third  division  of  the  trigeminal  is  the  inferior  dental 
nerve.  After  giving  off  the  mylohyoid  branch,  it  enters  the  long  in- 
ferior dental  or  mandibular  canal  (Fig.  50),  passing  along  with  the 
artery  and  the  venous  plexus  below  the  roots  of  the  molars  (see  Figs. 
49  and  50).  It  extends  as  far  as  the  central  incisors,  where  it  anasto- 
moses with  the  nerves  of  the  other  side.  At  the  mental  foramen  it 
gives  off  the  mental  branch  which  supplies  the  anterior  labial  surface 
of  the  mandible,  the  mucosa,  and  the  lower  lip  (see  Fig.  49).  In  its 
course  the  inferior  dental  nerve,  in  close  relationship  to  the  corre- 
sponding vessels,  gives  off  two  large  separate  branches,  a  posterior 
branch  to  the  molars,  and  a  middle  branch  between  the  dental  and 
the  mental  foramina  to  the  bicuspids. 

In  front  of  the  inferior  dental  nerve  (Figs.  49  and  50)  the  liitgual 
nerve  passes  to  the  tongue,  sending  off  on  its  way  a  side  branch  which 
is  minutely  broken  up  in  the  anterior  portion  of  the  mandible  (see 
Fig-  53).  In  the  bicuspid  region  it  ascends,  finely  distributing  itself 
in  the  periosteum  as  far  as  the  genial  tubercles. 

Branches  Constituting  the  Trigeminal  Nerve. — The  trigeminal 
nerve  is  made  up  of  the  following  branches: 

Sensory,  supplying  the  integument  of  the  head  and  face,  dura  mater, 
ball  of  the  eye,  mucous  membrane  of  the  nose  and  mouth,  anterior 
surface  of  the  outer  ear  (the  posterior  surface  of  the  ear  being  supplied 
by  the  cervical  nerves),  external  auditory  canal  (see  Fig.  54). 

Motor,  supplying  the  masticatory  muscles,  mylohyoid,  anterior 
belly  of  the  digastric,  tensor  of  the  soft  palate,  tensor  tympani. 

Gustatory,  supplying  the  anterior  two-thirds  of  the  tongue,  through 
the  chorda  tympani,  to  the  lingual  nerve  from  the  glossopharyngeus. 

Secretory  filaments  in  the  lingual  branch,  supplying  the  submaxillary 
and  the  sublingual. 


THE  NERVE  SUPPLY  OF  THE   MASTICATORY  APPARATUS  1.3o 

Vasoconstrictor  filaments,  belonging  to  the  cervical  s\-mpathetic 
S3'stcm. 

Plexuses  of  the  Trigeminal  Branches. — Biinte  and  Moral  have 
recently  emphasized,  more  strongly  than  this  had  been  done  before, 
the  anastomoses  within  the  trigeminal  area,  which  are  of  greatest 
importance  in  dentistry.  These  investigators  use  the  term  '  'inter- 
lacing of  nerves"  for  the  intercommunication  of  some  of  the  branches 

Fig.  53 


Lingual  N. 


Plexus  of  nasopalatine  and  anterior  palatine  nerves.     Distribution  of  lingual  nerve  in  mandible. 
(After  Biinte  and  Moral.) 

of  the  trigeminal  nerve,  the  most  important  of  which  are  the  following: 
The  anterior  palatine  nerve  (second  division)  communicates  in  the 
anterior  palatine  canal  with  the  nasopalatine  nerve  (second  division) 
(see  Figs.  49,  50,  and  53).  On  the  anterior  surface  of  the  mandible 
the  posterior,  middle,  and  anterior  superior  dental  nerves  anastomose 
with  one  another  (Figs.  48  and  52),  as  do  the  infra-orbital  nerves  in 
the  median  line  at  the  nasal  spine.     In  the  mandible,  the  inferior  dental 


136  TECHNIQUE  OF  LOCAL  ANESTHESIA 

nerves  of  either  side  communicate  with  one  another  at  the  symphysis. 
Numerous  terminal  plexuses  of  the  second  and  third  divisions,  which 
supply  the  alveolar  processes,  are  distributed  in  the  oral  mucosa  as  the 
posterior  and  anterior  superior  dental  nerves,  and  the  large  and  small 
palatine  7ierves.  From  the  auriculotemporal  nerve,  which  is  a  branch  of 
the  third  division  of  the  trigeminal,  the  parotid  branches  pass  to  the 
parotid  gland.  The  tensor  palati  and  the  tensor  tympani  muscles  are 
supplied  by  the  palatine  and  the  tympanic  nerves  which,  being  motor, 
are  given  off  from  the  otic  ganglion. 

Stimuli  Referred  by  Anastomoses. — The  nerves  supplying  the  in- 
dividual teeth  are  really  nerve  terminals,  which,  at  their  bases,  are  in 
communication  with  the  central  nervous  system  by  larger  tracts  of 
supply.  Since  they  stand,  however,  in  direct  relationship  to  neigh- 
boring areas,  it  is  easily  understood  why  pathological  processes  in  teeth 
very  frequently  involve  neighboring  normal  pulps.  It  is  not  surprising, 
then,  that,  especially  in  dental  disorders,  the  pain  is  so  extraordinarily 
intense,  frequently  affecting  large  neighboring  areas.  By  anastomoses 
with  the  opposite  side,  sensations  are  often  referred  to  that  side.  By 
the  relations  of  the  trigeminal  nerve  to  the  facial  nerve,  in  diseases  of 
the  lower  teeth,  pain  is  often  referred  to  the  ear  by  way  of  the  t}-mpanic 
branch,  the  mandibular  nerve  communicating  through  the  auriculo- 
temporal nerve  with  the  nerves  of  the  external  auditory  meatus,  the 
tympanic  branch  of  which  supplies  the  tympanic  membrane.  Radia- 
tion of  pain  from  the  alveolar  process  in  the  maxilla  to  the  regions 
of  the  temples,  the  eyes,  the  forehead,  the  neck,  or  even  the  upper  arm, 
is  frequently  noted.  The  same  corresponding  relationships  are  noted 
in  anesthesia. 

Communications  between  the  Divisions  of  the  Trigeminal  Nerve, 
Especially  the  First  and  Second  Divisions. —  It  is  a  very  interesting 
fact  that  strong  electric  currents  applied  to  the  teeth  or  the  oral  mucosa 
disclose  certain  relationships  existing  between  the  different  areas  of 
nerve  supply  in  the  facial  skull.  Oscillations  in  the  eye  and  an  increase 
in  the  lacrimal  secretion,  for  instance,  can  be  produced  by  applying 
strong  electric  currents  to  all  the  teeth,  both  upper  and  lower,  thereby 
stimulating  the  second  and  third  divisions  of  the    trigeminal    nerve. 


AREAS  OF  NERVE  SUPPLY  OF  THE   MASTICATORY  APPARATUS     Ki? 

Stimulation  of  the  soft  palate  is  followed  generally  only  by  an  increase 
in  lacrimal  secretion.  These  relationships  are  of  the  greatest  importance 
in  regard  to  pathology,  as  serious  disorders  of  the  teeth  may  involve 
the  organs  of  the  first  branch  of  the  trigeminal  nerve,  and  may  afifect 
even  other  neighboring  nerve  trunks,  as,  for  instance,  in  neuritis  of  the 
optic  nerve.  For  a  clear  understanding  of  these  conditions  the  anatomy 
of  the  divisions  of  the  trigeminal  nerve  must  be  fully  considered. 

The  first  division  of  the  trigeminal,  as  has  been  said  before,  sends 
three  branches  to  the  orbital  region  (Fig.  48),  the  nasal  nerve  entering 
the  orbit  by  way  of  the  sphenoidal  fissure  between  the  two  heads  of 
the  external  rectus,  while  the  lacrimal  nerve  and  the  frontal  nerve 
enter  the  orbit  through  the  upper  portion  of  the  fissure. 

It  seems  beyond  all  doubt  that  especially  the  nasal  nerve,  by  its 
relationships  to  the  oculomotor  and  the  optic  7ierves,  as  well  as  to  the 
lacrimal  sac,  conveys  impressions  from  the  second  and  third  divisions 
of  the  trigeminal  nerve  to  the  first  division,  producing  oscillation  of  the 
eye  and  increase  in  lacrimal  secretion.  The  sensory  nerves  of  the  palate 
also  being  derived  from  the  second  division  of  the  trigeminal  (the  an- 
terior palatine  nerve  supplying  the  hard  palate,  the  middle  and  pos- 
terior palatine  nerves  supplying  the  soft  palate),  these  too  may  influence 
the  first  division  of  the  trigeminal.  The  tensor  palati  muscle,  on 
the  other  hand,  is  supplied  by  branches  of  the  third  division  of  the 
trigeminal.  The  diagram  in  Fig.  49  illustrates  the  intimate  relations 
existing  between  the  trigeminal  nerve  and  the  branches  of  other  cranial 
nerves  invading  its  area  of  distribution. 

AREAS  OF  NERVE  SUPPLY  OF  THE  MASTICATORY 
APPARATUS 

In  order  to  oft'er  a  clear  picture  of  the  general  distribution  of  the 
individual  nerve  trunks  in  the  masticatory  apparatus,  especially  for 
the  purpose  of  local  anesthesia,  the  different  areas  have  been  marked 
in  colors  in  the  diagrams  (see  Figs.  54  to  60).  In  the  head  generally 
three  definite  nerve  areas  are  distinguished,  supplied  by  the  divisions 
of  the  trigeminal  nerve,  as  illustrated  in  Fig.  54. 


Fig.  54 


Superficial  area  of 
distribution  of 
posterior  branch 
of  cervical  N)i. 


Vertico-auricalo- 
mental  line 


Superficial  area  of_^ 
distribution      of 
cervical  plexus 


Distribution  of  trigeminal  nerve.     I,  II,  III,  divisions  of  trigeminal  N.     (After  Toldt.) 

Fig.  55 


Infra-orbital 
'     foramen 

Infra-orbi- 
tal N. 

Ant.  super,  den- 

■     tal  Nil. 

Middle   super, 
dental  Nn. 

Post,  super,  den- 
tal Xn. 

i}.£uccinator  N. 
Inferior  dental  N. 
Mental  N. 


Areas  of  nerve  supply  of  maxillary  apparatus.  Front  view.  Red  area:  inferior  dental  N.  Yellow 
area:  posterior  superior  dental  Nn.  Green  area;  Middle  superior  dental  Nn.  Blue  area:  anterior 
superior  dental  Nn. 


AREAS  OF  NERVE  SUPPLY  OF  THE  MASTICATORY  APPARATUS     139 

Superficial  Areas. — Looking  at  the  anterior  surface  of  the  skull, 
in  the  maxilla  three,  in  the  mandible  two  areas  are  distinguished  (see 
Fig.  55).  The  upper  incisors  and  canines  belong  to  the  blue  area  sup- 
plied by  the  anterior  superior  dental  nerves,  the  molars  to  the  yellow 

Fig.  56 


Infru-orhital  i\ 
Zygomatic  process 


Ant.  super,  dental  Kn 


Post,  super,  den- 
tal Nn. 


Fast,  super,  den- 
tal Nn. 


Incisors  and 
canines 


Molars 
Biciispids\ 

Middle  super,  dental  N71. 


Areas  of  nerve  supply  of  maxilla.  Blue  area:  anterior  superior  dental  Nn.  (incisor  and  canine 
region).  Green  area:  middle  superior  dental  N.  (bicuspid  region).  Yellow  area:  posterior  superior 
dental  Nn.  (molar  region). 


area  supplied  by  the  posterior  superior  dental  nerves,  while  the  bicuspids 
are  related  to  both  sides,  being  supplied,  in  the  green  area,  by  the 
anterior  and  middle  superior  dental  nerves.  The  blue  and  yellow  areas, 
therefore,  represent  portions  that  are  supplied  by  one  single  nerve 


140 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


branch  each,  while  the  green  areas  are  mixed.  In  the  latter  we  find  three 
branches,  the  middle  superior  dental  nerve  proper  which  supplies  the 
bicuspids,  and  the  anterior  and  posterior  superior  dental  nerves  on 
either  side  which  anastomose  with  the  middle  branch  (see  Fig.  48). 
The  suborbital  nerve  issues  by  the  infra-orbital  foramen  (see  Fig.  51). 

In  the  mandible,  the  red  area  supplied  by  the  inferior  dental  nerve 
is  the  predominant  one  (see  Fig.  55).  Only  in  the  posterior  section; 
the  mucosa  at  the  molars  is  supplied  by  sensory  filaments  from  the 
buccinator  nerve  (see  the  orange  area  in  Fig.  55). 

Fig.  57 
Kam-palathie  notvh 


Anastomosis  bftueett 
ante]  lot  palatine 
and  naso  palatine 
Kn. 


Areas  of  nerve  supply  of  palatal  surface  of  maxilla.     Blue  area:  nasopalatine  N.     Red  area: 
anterior  palatine  N.  (molar  region). 

Maxilla. — Viewing  it  laterally,  the  maxilla  may  be  divided  into  three 
areas,  shown  as  blue,  green,  and  yellow  in  Fig.  56,  being  sharply  demar- 
cated at  the  teeth  supplied.  At  the  level  of  the  tuberosity  the  individual 
posterior  superior  dental  nerves  penetrate  in  several  branches  the  facial 
wall  (see  Figs.  48,  51,  and  52).  These  nerve  branches,  in  their  course 
to  the  tuberosity,  can  be  reached  by  the  hypodermic  needle  and 
anesthetized   by  injection   at  the  tuberosity  of  the   superior  maxillary 


Fig.  58 


Anterior  retjion 
Areas  of  nerve  supply  of  palatal  surface  of  maxilla.     Red  area:  anterior  palatine  N.  (molar  region). 
Blue  area:    nasopalatine  N.  (incisor  and  canine  region).     The  bicuspid  region  is  supplied  b;^  both 
branches. 

Fig.  59 


Mental  for 1 


Areii  paribj  supplied  bij  bncdnator  iV. 
Area  of  nerve  supply  of  anterior  section  of  mandible.     Red  area:  inferior  dental  N.     From  the 
mental  foramen  emerges  the  mental  N.      The  mucous  membrane  in   the  molar  region  is  partly 
supplied  by  sensoiy  fibers  of  the  buccinator  N. 


142 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


bone.  The  nerves  supplying  the  green  and  blue  areas  pass  behind  the 
facial  plate  of  the  alveolar  process,  partly  into  the  maxillary  sinus 
(see  Figs.  48  and  52).  This  plate,  as  has  been  pointed  out  before,  is 
cancellous  in  certain  portions  (see  Fig.  20),  and,  being  rather  thin  gener- 
ally (Fig.  43),  is  most  favorable  for  the  diffusion  of  injected  fluids. 

Fig.  60 


Area  supph 
by  inferior^, 
dental    and 
Ungual  Nn. 


Area  supplied  Lingual  N.  Mylo-hyoid  N. 
by   inferior 
dental  N. 

Areas  of  nerve  supply  of  lingual  section  of  mandible.     Red  area:  inferior  dental  N.     The  mylohyoid 
N.  branches  off  at  inferior  dental  foramen.     Blue  area;  lingual  N. 


Palatal  Surface. — The  palatal  surface  of  the  maxilla  may  be  divided 
into  an  anterior  blue  and  a  posterior  red  section.  The  latter  is  supplied 
by  the  anterior  palatine  nerve  (see  Fig.  57),  which  emerges  upon  the  hard 
palate  at  the  posterior  palatine  foramen  above  the  third  molar  (see  Figs. 
50,  51,  and  53),  and,  passing  forward  and  toward  the  median  line, 
communicates  in  front  with  the  nasopalatine  nerve  (see  Figs.  50  and  53) . 
The  filaments  of  the  latter  supply  the  area  at  the  anterior  teeth  as  far 
as  the  bicuspids  which,  as  in  the  mandible,  are  in  communication  with 
both  branches.  Viewed  laterally,  these  two  nerve  branches,  then, 
are  distributed  over  the  area  just  described  (see  Figs.  50,  53  and  58). 


DISTRIBUTION  OF  NERVES  IN  THE  ALVEOLAR  PROCESS  AND  PULP     143 

Mandible. — The  nerve  supply  of  the  mandible  is  simpler.  It  is 
dominated  entirely  by  the  inferior  dental  nerve,  which  passes  forward 
in  the  mandibular  canal  (see  Fig.  49).  A  lateral  view,  therefore,  shows 
a  predominant  red  area  which  is  interrupted  by  the  emerging  mental 
nerve,  which  is  a  branch  of  the  inferior  dental  (see  Figs.  49  and  59). 
Only  in  the  region  of  the  molars,  an  orange-yellow  area  indicates 
another  invading  nerve  branch,  the  buccinator  nerve,  which  supplies  the 
anterior  mucosa  of  the  molars  and  bicuspids  (see  Figs.  55  and  59). 

The  lingual  surface  of  the  mandible  is  supplied  jointly  by  the 
inferior  dental  nerve  and  one  of  its  coordinate  branches,  the  lingual 
nerve.  The  latter  is  a  large  branch,  placed  in  front  of  the  inferior 
dental  nerve  and  ascending  in  the  region  of  the  first  bicuspid  to  the 
alveolar  process  as  far  as  the  incisors,  where  it  is  finely  distributed  in 
the  periosteum  (see  Figs.  53  and  60).  Some  of  its  terminal  filaments 
in  the  vicinity  of  the  genial  tubercles  probably  extend  through  fora- 
mina to  the  anterior  mandibular  canal  (see  Fig.  34).  Shortly  before 
entering  the  inferior  dental  foramen  the  inferior  dental  nerve  gives  off 
a  motor  branch,  the  mylohyoid  nerve  (see  Figs.  49,  50,  and  60). 


THE  MINUTE  DISTRIBUTION  OF  NERVES  IN  THE  ALVEOLAR 
PROCESS  AND  THE  PULP 

Periosteum. — Within  the  alveolar  processes  the  nerve  trunks  are 
most  minutely  distributed.  The  periosteum  as  well  as  the  pericementum 
are  specially  richly  endowed  with  sensory  filaments.  Fig.  61  represents 
Vaters  or  Pacini's  corpuscles,  sensory  end  organs,  which  are  always 
present  in  the  periosteum. 

Pulp. — The  nerve  trunks  of  the  palp  are  generally  large  nerve  fiber 
bundles  branching  out  at  the  periphery  of  as  well  as  laterally  in  the 
odontoblastic  layer  (Fig.  62),  where  they  break  up  into  delicate,  long, 
non-medullated  fibrils,  which  terminate  in  a  delicate  end  plexus  at  the 
internal  terminal  lamina  (see  Fig.  64). 

In  osmium  preparations  we  note  in  this  end  plexus  delicate  button - 
shaped  end  bulbs,  these  being  characteristic  of  sensory  nerve  terminals. 


144 


TECHNIQUE  OF  LOCAL  ANESTHESIA 
Fig.  6i 


Nerves  in  the  periosteum  and  interosseous  ligament  in  the  foreaim  with  Pacinian  corpuscles: 
I,  radius;  2,  ulna;  3,  interosseous  membrane;  4,  tendon  of  biceps  brachii  M.;  5,  tendon  of  brachialis 
M.;  6,  supinator  M.;  7,  pronator  quadratus  M.;  8,  median  N.;  9,  interosseus  antebrachii  volaris  N.; 
10,  branches  of  flexor  profundus  digitorum  M.;  11,  periosteal  branch  to  ulna;  12,  nerve  to  flexor 
pollicis  longus  M.;  13,  radial  N.;  14,  trunk  of  interosseous  Nn. ;  15,  second  branch  of  radial  N.;  16, 
periosteal  branch  to  radial  N.;  17,  branch  of  interosseous  Nn. ;  18,  communicating  branch  from 
interosseus  antebrachii  volaris  N.;  19,  20,  21,  branches  of  interosseous  Nn.;  22,  ulnar  N.;  23,  24, 
branches  of  interosseous  Nn.;  25,  26,  27,  branches  of  interosseus  volaris  N.;  28,  interosseus  ante- 
brachii posterior  N.     (From  Rauber  and  Kopsch.) 


DISTRIBUTION  OF  NERVES  IN  THE   PULP 


145 


In  their  course,  they  arborize  around  the  odontoblasts ,  and  in  obHque 
cross-sections  the  reticuhim  issuing  from  larger  fibers  and  surrounding 
the  odontoblasts  can  be  plainly  observed  (see  Fig.  65). 

Sensibility  of  the  Dentin. — From  the  above  it  follows  that  the  odon- 
toblastic layer  represents  the  most  important  tissue  area  of  the  pulp, 
as  well  as  of  the  entire  tooth.  In  this  area  the  most  delicate  tendrils 
of  the  nerve  filaments  are  distributed,  arborizing,  together  with  a 
graceful  network  of  lymphatic  capillaries,  around  the  odontoblasts,  the 
bloodvessels  also  breaking  up  here  into  innumerable  capillary  loops. 


v'    I         /       '       ^      ■  \ 
ok.     <?/     gI     jv.         a 


Od. 


Nerves  and  vessels  in  the  pulp.      X  56.     D,  dentin;  Od,  odontoblasts;  G,  vessels;  N,  nerves; 
A ,  ramusculi  of  nerve  fibers. 


Since  the  odontoblasts  with  their  cell  processes  control  the  nutrition 
and  the  sensitiveness  of  the  dentin,  which  forms  the  bulk  of  the  tooth, 
their  relationship  to  the  nervous  and  lymphatic  system  is  not  only 
easily  understood,  but  is  a  matter  of  course.  Since,  on  the  other  hand, 
Tomes'  fibrils  are  undoubtedly  of  a  protoplasmic  nature,  nerve  ten- 
drils, however,  can  be  traced  only  beneath  the  odontoblastic  layer, 
the  transmission  of  stimuli  in  the  dentin  can  be  effected  only  b}'  the 
medium  of  the  protoplasm,  whence  they  are  conveyed  to  the  sensory 
end  organs  at  the  odontoblastic  cells. 
10 


fp  tissue 


Nerve  stejn 
Distribution  of  bundle  of  nerve  fibrillae  in  odontoblastic  layer.     Stained  with  osmium. 

Fig.  64 

Od. 

/ 
/ 


^ 


Od.F 

Nerve  fibers  extending  between  the  odontoblasts  to  the  dentinal  layer.  X  940.  iV.i^.,  nerve  fibers; 
Od.,  odontoblasts;  /,  internal  terminal  lamina;  Od.F..  odontoblastic  processes;  N.P..  terminal  nerve 
plexus. 


DISTRIBLTIOX  OF  XEKVES  I X   THE   PULP  147 

Structure  of  the  Nerve  Filaments  in  the  Pulp. — The  nerves  of  the 
pulp  are  deri\-ed  from  the  sensory  filaments  of  the  trigeminal  nerve, 
and  enter  the  pulp  in  one  or  more  thick  trunks  at  the  apical  fora- 
men together  with  the  bloodvessels.  In  the  middle  portion  of  the 
pulp  canal  these  trunks  branch  out  so  much  that,  in  incisors,  for 
instance,  from  thirty  to  forty  bundles  may  be  counted.    These  bundles 

Fig.  65 


Od. 


Horizontal  section  of  odontoblasts  and  nerve  fibrils  arborizing  around  them.  X  1560.  U, 
odontoblasts,  surrounded  with  nerve  fibrils;  N.F.,  nerve  fibrils;  P,  protoplasm;  K.  nucleus;  Od., 
odontoblasts. 

are  cylindrical  and  composed  of  a  group  of  medullated  nerve  fibers  of 
from  about  6  to  10  microns'  thickness  (see  Fig.  65).  Each  bundle  is 
surrounded  by  a  sheath  of  connective  tissue  similar  to  the  perineurium. 
The  fibrillae  in  these  bundles  run  mostly  in  the  direction  of  the  long 
axis  of  the  tooth.  They  break  up,  by  repeated  dichotonwiis  division 
(see  Fig.  62),  into  innumerable  brush-like  amyelinic  filaments,  termin- 
ating beneath  the  dentin  (at  the  internal  terminal  lamina)  in  a  delicate 


148 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


plexus,  these  non-meduUated  telodendrlons  of  from  2  to  3  microns' 
thickness  exhibiting  generally  button-shaped,  delicate  end  bulbs  (see 
Figs.  63  and  64).  These  telodendrlons  surround  the  odontoblasts  on  all 
sides,  partly  in  rings,  partly  in  spirals,  and  represent  complicated,  free 
peripheral  endings  similar  to  the  telodendrlons  of  the  sensory  nerves 
of  the  muscles  and  tendons. 

Fig.  66 


Nerves  of  capillaries.     (After  Joris.)     (From  Rauber  and  Kopsch.) 


Nerve  Supply  of  the  Vascular  Walls. — A  final  word  should  be  said 
as  to  the  nerve  supply  of  the  bloodvessels  and  capillaries.  The  blood- 
vessels are  supplied  by  motor  as  well  as  sensory  plexuses,  most  of  the 
latter  belonging  to  the  great  sympathetic  system.  Their  fibers  are  non- 
medullated,  generally  terminating  within  the  adventitious  coat  (tunica 
adventitia)  and  the  tunica  media  in  a  sensory  end  plate.  The  capil- 
laries are  enmeshed  in  a  reticulum  of  delicate  neurofibrillse,  as  illus- 


MUCOUS  ANESTHESIA  149 

trated  in  Fig.  66.  These  fibrilhe,  when  acted  upon  by  suprarenin, 
bring  about  the  contraction  of  the  vascular  walls,  maintaining  the 
vascular  constriction  so  desirable  during  anesthesia. 


THE   TECHNIQUE   OF  LOCAL  INJECTION 

After  the  above  considerations,  the  technique  of  injection  is  merely 
a  question  of  logical  utilization  of  the  factors  observed.  After  having 
gained  definite  points  by  which  to  follow  our  lines  of  procedure,  based 
partly  on  the  peculiarities  of  the  bony  structures,  partly  on  the  nerve 
supply,  we  are  now  on  a  well-marked  road  which  is  sure  to  lead  us 
to  the  desired  goal.  That  the  tactics  of  injection  to  be  demonstrated 
are  the  correct  ones,  has  been  evinced  by  the  excellent  results  obtained 
so  far. 

Local  injection  anesthesia  in  the  masticatory  apparatus  as  formerly 
employed  comprised  merely  anesthesia  of  the  mucous  membrane,  until 
within  recent  years  conductive  anesthesia  was  introduced.  It  was  not 
until  the  adoption  of  this  method  that  our  successes  in  this  field 
became  truly  phenomenal,  to  mention  only  the  effect  of  mandibular 
anesthesia,  which  method  is,  indeed,  the  first  to  guarantee  complete 
and  reliable  anesthesia  of  the  mandible.  It  is,  indeed,  an  unassailable 
fact  that  anesthesia  of  lower  molars  by  the  old  method  of  injection 
into  the  mucosa  is  successful  only  in  certain  favorable  cases,  whereas 
generally  it  is  a  more  or  less  complete  failure. 


MUCOUS  ANESTHESIA 

B}'  mucous  anesthesia  we  mean  anesthesia  of  a  circumscribed  por- 
tion of  the  jaw  by  way  of  the  oral  mucosa.  The  course  of  this  anesthesia 
varies  according  to  the  character  of  the  mucous  membrane,  the  manner 
of  insertion  of  the  needle,  and  the  pressure  under  which  the  fluid  is 
injected  into  the  tissues.  By  infiltrating  the  entire  tissue  area  with  a 
solution,  the  functions  of  the  nerves  supplying  this  area  are  paralyzed. 
In  ever^'  case  the  anesthetizing  effect  is  due  to  the  contact  of  the  anes- 


150 


TECHNIQUE  OF  LOCAL  ANESTLIESIA 


thetic  with  the  sensory  nerve  fibers,  which  are  gradually  paralyzed 
within  from  five  to  ten  minutes,  depending  upon  the  anesthetic 
employed.  If  the  correct  technique  is  followed,  our  novocain  solution 
produces  complete  anesthesia  of  the  injected  area  within  from  eight 
to  ten  minutes,  lasting  with  full  intensity  for  about  one-half  hour, 
after  which  it  wears  off  very  gradually. 

Fig.  67 


Mucous  anesthesia  in  maxilla  in  case  of  abscessed  upper  left  canine.  The  needle  is  inserted  in  the 
gingival  papilla  of  the  central  incisor  and  advanced  horizontally  in  distal  direction.  Injection  is 
made  into  the  periosteum.     Syringe  is  held  like  penholder. 


Since  mucous  anesthesia  in  the  jaws  depends  primarily  upon  inter- 
vention in  the  periosteum  and  its  constituent  tissue  elements,  the 
mucosa  proper  playing  but  a  secondary  role,  it  would  be  more  correct 
to  speak  of  periosteal  anesthesia.  Success  depends  less  upon  injection 
into  the  submucous  tissue  than  into  the  periosteum.     The  periosteum 


.1/  rCO  us  ANESTHESIA 


151 


in  the  jaws  covers  the  bony  surfaces  in  an  extremely  taut  and  firm 
layer;  injection  below  this  layer,  therefore,  requires  considerable 
pressure. 

Fig.  68 


Points  of  injection  for  anterior  upper  teeth:  i,  injection  for  abscessed  upper  left  lateral  incisor; 
2,  injection  for  upper  right  central  and  lateral  incisors;  3,  injection  for  upper  right  canine;  4,  injec- 
tion for  upper  right  bicuspid.  The  red  crosses  indicate  the  points  of  injection,' the  red  arrows  the 
direction  of  the  needle. 


Fig. 


Diagram  showing  method  of  injection  in  maxilla  (upper  right  canine).     The  red  arrows  indicate  the 
correct,  the  black  arrows  the  incorrect  position  of  the  needle. 

Injection  into  the  Mucosa. — Before  inducing  anesthesia,  the  neck 
band,  described  above,  is  placed  upon  the  patient,  not  too  tighth- 
(see  Fig.  5).  The  injecting  syringe  is  held  like  a  pen  (see  Fig.  67),  and 
the  needle  is  placed  at  an  almost  right  angle  upon  the  mucosa,  which 
has  been  disinfected  with  tincture  of  iodin  (see  Fig.  81).  The  needle 
is  then   slowly   pushed   through   to    the  periosteum,   and   the  syringe 


152 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


inclined  so  that  the  direction  of  the  needle  canal  is  at  an  acute  angle 
to  the  bone  (see  Figs.  68  and  69).  The  needle  is  then  advanced  a 
short  distance  under  the  periosteum,  and  the  needle  point  fixed  with 
the  left  hand,  while  the  right  hand  is  holding  the  syringe  in  position 
(see  Fig.  103).    The  syringe  is  mounted  with  hub  B  or  C  and  needle 


Syringe  mounted  with  hub  B  and  needle  No. 
17  a,  for  injection  in  anterior  teeth. 


Syringe  mounted  with  hub  C  and  needle  No. 
17  a,  for  injection  in  anterior  teeth. 


No.  17  a  (see  Figs.  70  and  71).  The  orifice  of  the  needle  should  always 
be  pointed  toward  the  bone  in  the  manner  illustrated  in  Fig.  '/2.  While 
with  the  left  hand  the  lip  is  lifted  away  as  much  as  possible  to  gain  an 
unobstructed  field  of  vision  (see  Fig.  67),  a  quantity  of  liquid  is  injected 
without  further  advancing  the  needle  along  the  bone.     The  syringe  is 


MUCOUS  ANESTHESh 
Fig.  72 


153 


4  ^ 

Position  of  needle  in  mucous  anesthesia,  aperture  of  needle  pointing  toward  the  bone:  a,  correct 
position;  b,  incorrect  position.  The  point  of  the  needle  is  forced  into  the  periosteum  and  to  the 
bone.     (After  Seidel.) 

Fig.  73 


Points  of  injection  in  maxilla  in  mucous  and  conductive  anesthesia:  U,  line  of  reflection  of  mucous 
membrane;  I,  injection  for  upper  right  central  incisor;  2,  for  upper  right  lateral  incisor;  3,  for  con- 
ductive anesthesia  of  upper  right  lateral,  canine,  and  first  bicuspid,  the  needle  to  be  advanced  to 
infra-orbital  foramen;  4,  for  upper  right  second  bicuspid;  5,  for  upper  right  first  molar;  6,  conductive 
anesthesia  at  maxillary  tuberosity  for  upper  right  first,  second,  and  third  molars;  7,  conductive 
anesthesia  for  upper  right  tliird  molar. 


154 


TECHXIOUE  OF  LOCAL  ANESTHESIA 


then  cautiously  and  slowly  withdrawn,  and  the  point  of  injection  is 
compressed  with  the  index  finger  of  the  free  hand  for  about  fifteen 
seconds. 

Fig.  74 


Syringe  mounted  with  hub  B  and  needle  No.  17  c,  for  injection  in  posterior  teeth 


In  the  posterior  portions  of  the  gums,  owing  to  the  interference  of 
the  cheek,  the  needle  cannot  be  placed  at  a  right  angle,  and  must 
therefore  be  advanced  obliquely  (see  Figs.  73  and  75),  the  main  object 
being  to  reach  the  periosteum  as  quickly  as  possible,  slide  under  it, 
and  there  inject.  In  this  case  the  syringe  is  mounted  with  hub  A  and 
needle  No.  17  c,  as  illustrated  in  Fig.  74. 

Maxilla. — Buccal  and  Labial  Injection. — Injections  in  the  buccal 
mucosa  are  generally  made  in  the  manner  just  described.     Repeated 


M  L  -CO  US  A  NES  Til  ESI  A 


155 


insertions  of  the  needle  should  be  avoided  as  much  as  ]30ssible,  and  an 
effort  be  made  to  infiltrate  the  desired  area  at  one  insertion,  which  is 


Position  of  needle  for  horizontal  injection  in  several  upper  teetli;     Needle  yellow;  a,  labial  injection; 

b,  buccal  injection. 

Fig.  76 


Position  of  needle  for  injection  in  upper  canine.     Needle  yellow:  a,  labial  injection; 
h,  palatal  injection. 

always  possible  in  single  teeth.     The  anesthetization  e^"en  of  se\eral 
teeth  can  be  accomplished  at  one  buccal  insertion,  especialh-  in  bicuspids 


156  TECHNIQUE  OF  LOCAL  ANESTHESIA 

and  molars,  which  permit  of  straightforward  palpation  with  the  long 
needle  (see  Fig.  75).  In  these  teeth  the  needle  is  inserted  at  the  level  of 
the  middle  root  portion  at  a  right  angle  to  the  vertical  axis  of  the  roots. 
At  the  sharp  curve  in  the  canine  region,  however  (see  Fig.  75),  the  needle 
is  inserted  at  the  level  of  the  root  apex  of  the  canine  and  advanced 
under  the  periosteum,  where  the  injection  is  slowly  made  under  pres- 
sure (see  Fig.  76).  If  the  incisors  and  bicuspids  on  the  same  side  are  • 
also  to  be  anesthetized,  the  needle  is  pushed  forward  from  the  canine 
root,  while  slowly  emptying  the  barrel,  in  the  direction  of  the  anterior 

Fig.  77 


Position  of  needle  for  mucous  anesthesia  in  upper  first  bicuspid.     Needle  yellow.    Above  is  seen  the 
infra-orbital  foramen:  a,  buccal  injection;  b,  palatal  injection. 

nasal  spine  into  the  region  of  the  root  apex  of  the  central  incisor, 
where  the  remainder  of  the  solution  is  injected  (see  Fig.  73).  After 
the  syringe  has  been  refilled,  the  needle  is  again  inserted  at  the  former 
point  at  the  canine  root,  but  in  the  direction  of  the  root  apices  of  the 
bicuspids,  where  the  barrel  is  also  slowly  emptied.  If  the  second 
bicuspid  is  also  to  be  anesthetized,  the  needle  must  be  advanced  to 
the  root  apex  of  that  tooth  (see  Fig.  77). 

If  mucous  anesthesia  has  been  correctly  executed  no  swelling  occurs, 
the  formerly  reddish  mucous  membrane  becoming  pale  and  sometimes 


M  UCO  US  A  NES  THESIA 


157 


entirely  anemic.  In  spongy  gingival  tissue,  however,  swelling  cannot 
be  prevented,  as  in  such  cases  the  periosteum  generally  does  not  firmly 
cover  the  bone  surface.  The  gradual  expansion  of  the  anemic  area 
should  always  be  carefully  noted.  After  successful  injection  the 
anemia  frequently  involves  the  palate,  owing  to  diffusion  within  the 
interdental  papilla. 

Fig.  78 


Injection  in  palatal  mucous  membrane  at  lateral  incisor  region.    Syringe  is  held  like  penholder. 

Palatal  Injection. — Mucous  anesthesia  from  the  palatal  surface  of  the 
maxilla  requires  special  description.  For  palatal  injection  the  needle 
is  always  inserted  in  the  mucosa  behind  the  tooth  to  be  anesthetized 
(see  Figs.  69,  75  to  79),  and  is  at  once  cautiously  and  slowly  advanced 
parallel  to  the  alveolar  process  into  the  vicinity  of  the  root  apex 
(see  Figs.  69  and  79),  where  a  small  quantity  of  the  solution,  /.  e.,  froni 
J  to  J  c.c,  is  deposited  (see  Fig.  68).  In  the  deep  strata  of  the  anterior 
palatine  area  the  conditions  for  diffusion  are  most  faxorable,  and  the 


158 


TECHNIQUE  OF  LOCAL  ANESTLIESIA 


injection  can  be  made  much  more  easily,  with  less  pressure  and  less 
pain,  than  near  the  cervical  margin  of  the  gingival  tissue,  where  the 
taut  circular  ligament  offers  considerable  resistance  (see  Figs.  80  and  81). 
Injection  at  the  Posterior  Palatine  Foramen. — The  above  procedure 
is  followed  for  all  upper  incisors,  canines,  and  bicuspids,  but  not  for 
upper  molars.      In   these,   one   single   insertion   of   the   needle   at   the 

Fig.  79 


Injection  in  palatal  mucous  membrane  in  bicuspid  region.     Syringe  is  held  like  penholder. 

posterior  palatine  foramen  suffices,  this  foramen  being  situated  under 
a  slight  depression  in  the  mucosa  near  the  root  apices  of  the  third 
molar  (see  Fig.  82).  The  posterior  palatine  foramen  is  usually  located 
^  cm.  from  the  posterior  limit  of  the  alveolar  process  and  above  the  last 
erupted  molar  (see  Figs.  50,  53,  80,  and  82),  up  to  the  tenth  or  eleventh 
year  of  life  above  the  first  molar,  after  the  eruption  of  the  second  molar 
above  this  tooth,  and  finally  above  the  third  molar  (see  Figs.  2-j  to  31, 


AI UCO  US  A  NESTIIESIA 
Fig.  So 


159 


Posterior  pal- 
atine fora- 


Bony  surface  of  palate.     The  red  crosses  indicate  points  of  injection  for  mucous  anesthesia;  the 
soUd  red  arrows  the  points  of  injection  at  the  posterior  palatine  foramina. 


Position  of  needle  for  injection  in  upper  central  incisor.    Needle  yellow:  a,  labial  injection; 
b,  palatal  injection. 


160 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


49,  50,  and  82).  If  the  posterior  portion  of  the  alveolar  process  has 
been  absorbed,  it  is  best  to  inject  near  the  apex  of  the  palatal  root 
of  the  first  or  second  molar  to  be  anesthetized.  The  needle  is  inserted 
in  the  mucous  fossa,  the  syringe  being  directed  almost  parallel  to  the 
alveolar  arch  and  the  molar  root  and  inclined  slightly  backward 
to  the  tuberosity;  the  needle  is  then  advanced  into  the  foramen  and 
from  6  to  10  drops  of  the  solution  are  evacuated.     If  a  larger  quantity 

Fig.  82 

Central 
Lateral    incisor   Incisive  papilla 
incisor 
Canine 

Transverse 
palatal 
rugx 


Point  of  injection 
at  posterior 2ml-  ' 
aline  foramen 


Palato-maxillary  , 
depression 


Soft  palate^' 


,^^  Point  of  injection 
(it  posterior  pal- 
atine foramen 


Z.-^  Orifices  of  pal- 
atine glands 


Anterior  pillar 
ior  pillar 


Mucous  surface  of  palate.     The  red  cross  marks  the  point  of  injection  at  the  posterior  palatine 
foramen  on  either  side.      (After  Spalteholz.) 

is  employed,  there  is  danger  of  injecting  the  solution  into  the  loose 
pharyngeal  tissue,  thereby  producing  disagreeable  difficulties  in  deglu- 
tition. Strictly  speaking,  conductive  anesthesia  is  produced  by  this 
method,  as  the  anterior  palatine  nerve  trunk  is  blocked  at  its  descent 
from  the  posterior  palatine  foramen  (see  Figs.  50  and  53).  The  pos- 
terior portion  of  the  alveolus  in  the  molar  region  is  completely  anes- 
thetized by  this  injection. 


MUCOUS  ANESTHESIA 


Kil 


Injection  in  tlic  Anterior  Palatine  Fossa  Contraindicated. — Experience 
has  shown  that  the  anterior  palatine  fossa  with  its  four  foramina, 
situated  in  the  anterior  portion  of  the  palatal  roof,  is  not  a  suitable 
location  for  anesthesia,  as  injection  in  these  foramina  for  the  sake  of 


Fig.  83 


Mi'iital  fora 


ilenitil  {incisive) 
fossa 


Cniiive     Mental  pro- 
fossa         tiibeiunce 


Points  of  injection  for  mucous  anesthesia  in  external  surface  of  mandible.  Red  crosses  indicate 
points  of  injection;  small  red  arrows,  direction  of  needle;  two  large  arrows,  direction  of  needle  for 
injection  in  mental  foramen  and  fossa.  On  the  internal  surface  of  the  ramus  are  marked  the  points 
for  injection  at  mandibular  foramen. 


paralyzing  the  nasopalatine  nerves  usually  involves  severe  pain,  possibly 
owing  to  compression  of  these  nerve  trunks.  Moreover,  in  regard  to 
effect  no  advantages  are  to  be  derived  from  such  an  injection,  and  the 
advocated  palatal  injection  behind  each  tooth  (see  Figs.  69,  78,  and  79) 

11 


162 


TECHNIQUE  OF  LOCAL  ANESTHESIA 

Fig.  84 
o  b 


Position  of  needle  for  injection  in  lower  molars.     Needle  yellow:  o,  buccal  injection; 
6,  lingual  injection. 


Fig.  85 


Injection  in  mandibular  mucous  membrane  for  anesthesia  of  lower  second  bicuspid.  The  needle 
is  inserted  in  the  eminence  of  first  bicuspid  directly  below  gingival  papilla.  Syringe  is  held  like 
penholder. 


M  L'CO  US  A  NESTJIESIA 
Fig.  S6 


163 


Injection  for  anesthesia  of  lower  anterior  teeth.     The  long 
mucous  membrane,  and  advanced  to  the  mental  fossa. 


Fig. 
h 


needle  is  inserted  in  the  reflection  of 
Syringe  is  held  like  penholder. 


Position  of  needle  for  injection  in  lower  canine.     Injection  in  mental  fossa.    Needle  yellow: 
a,  labial  injection;  b,  lingual  injection. 


164 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


is  more  expedient  and  successful,  and  above  all  is  tolerated  surprisingly 
well  and  causes  a  minimum  of  pain. 

Mandible. — In  the  mandible,  mucous  anesthesia  is  employed  as  an 
adjuvant  to  mandibular  anesthesia.  In  loose  roots  and  teeth  and  in 
anterior  teeth  it  may  be  successfully  employed  alone  (see  Fig.  83). 


Fig.  88 


^'^  -.,_^  Condyloid 
i^^f  process 


Lingual  points  of  injection  for  mucous  anesthesia  of  mandible.  Red  crosses  indicate  points  of 
injection;  red  arrows,  direction  of  needle;  black-dotted  line,  the  angle  of  the  ramus  to  the  body  of 
the  jaw. 

Injection  in  the  Gingival  Papillce  in  the  Mandible. — Anesthesia  of  the 
anterior  teeth  must  be  clearly  distinguished  from  anesthesia  of  the  pos- 
terior teeth,  including  the  first  bicuspid.  While  injection  in  the  latter 
is  always  to  be  made  in  the  region  of  the  gingival  papillae,  advancing 
the  needle  horizontally  along  the  alveolar  margin  (see  Figs.  83  and  84), 
which  is  the  only  favorable  place  for  diffusion  into  the  fundus  of  the 
alveoli  (see  Figs.  41,  44,  and  85),  anesthesia  of  the  anterior  teeth, 
including  the  canines,  is  obtained  in  the  following  manner: 

Injectio7i  in  the  Mental  Fossa. — The  lip  is  raised  and  the  needle  is 
inserted  in  the  mucous  membrane,  which  has  been  previously  sterilized 
with  tincture  of  iodin,  at  about  the  level  of  the  root  apex  of  the  canine 


M I  TO  US  A  NEST  II  ESI  A 


16.5 


(see  Figs.  86  and  87),  and  pushed  forward  and  downward  with  a  sHght 
inclination  mesially,  until  the  mental  fossa  is  reached  (see  Figs.  18,  20, 
21,  22,  24,  86,  and  87).  This  fossa  is  situated  below  the  root  apex  of 
the  canine  and  that  of  the  lateral  incisor,  and  has  numerous  foramina 
through  which  the  injected  solution  penetrates  into  the  interior  of 
the  jaw'  (see  Figs.  12  to  25).  While  advancing  the  needle,  a  few  drops 
of  the  solution  are  evacuated,  while  the  bulk  of  the  solution  (about 
I  c.c.)  is  injected  in  the  fossa,  thereby  invariably  producing  complete 
anesthesia  of  the  canine  and  the  two  incisors  on  the  injected  side. 

Fig.  89 


Lingual  injection  between  lower  canine  and  bicuspid  for  anestliesia  of  lingual  nerve  fibers. 

Lingual  Injection. — The  small  quantity  of  solution  left  in  the  syringe 
after  the  last  procedure  should  be  injected  lingually  behind  the  central 
incisors  and  in  the  line  of  their  long  axis  (see  Fig.  88),  also  between  the 
canine  and  the  first  bicuspid  (see  Fig.  89),  in  order  to  paralyze  the  fila- 
ments of  the  lingual  nerve  (see  Fig.  53)  as  well  as  to  force  the  solution  into 
the  interior  of  the  jaw  through  the  foramina  situated  lingually  at  the 
internal  genial  tubercles  (see  Figs.  32  and  33).    The  syringe  is  mounted 


166 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


with  the  curved  middle  piece  E,  the  hub  B,  and  the  needle  Xo.  17a 
(see  Figs.  2  and  90),  and  the  needle  is  inserted  below  the  taut  mucous 
membrane  of  the  central  incisor  and  at  once  slowly  advanced  along  the 
periosteum,  while  discharging  some  solution,  parallel  with  the  mandib- 


FiG.  90 


Fig.  91 


Syringe  mounted  with  middle  piece  E,  luib  B. 
and  needle  No.  17a,  for  lingual  injection. 


Syringe  mounted  with  middle  piece  E.  hub 
C,  and  needle  No.  17c,  for  lingual  injection  in 
lower  molars. 


ular  process,  to  the  vicinity-  of  the  root  apex.  An  injection  is  also 
made  between  the  canine  and  bicuspid  (see  Figs.  87  and  89),  advancing 
the  needle  directly,  while  slowly  discharging,  to  about  the  middle  of  the 
canine  root  length,  in  both  cases  injecting  about  |  c.c.  of  the  solution. 


.yrcous  axestiiesia  107 

Thus  in  anterior  hnvcr  teeth  it  is  i:)ossil)le  to  inject  locally,  Init  if  several 
teeth  are  to  be  anesthetized  simultaneously,  it  is  advisable  to  resort  to 
mandibular  anesthesia.  The  method  described  is  invariably  successful, 
e\en  in  periostitis,  the  mental  fossa  being  a  most  excellent  place  of 
\'antage  for  injection  at  a  distance  from  the  alveolar  process  and  for 
difTusion  of  the  solution. 

Mucous  Anesthesia  in  Lower  Molars. — In  all  lower  molars  only  one 
procedure  of  mucous  anesthesia  is  applicable  as  an  adjuvant  to  con- 
ductive anesthesia,  this  procedure  being  as  follows:  The  needle  is  in- 
serted slightly  below  the  cervical  margin  of  the  gingiva  in  the  centre 
of  the  tooth  lying  anteriorly  to  the  tooth  to  be  anesthetized,  advancing, 
as  in  the  maxilla,  buccally  and  straight  to  the  periosteum,  gliding  under 
it  a  little  forward,  but  not  farther  than  the  centre  of  the  tooth  to  be 
anesthetized,  and  injecting  there  from  i  to  ij  c.c.  of  the  solution 
(see  Figs.  83  and  85).  The  syringe  is  mounted  with  the  hub  B  and 
the  needle  No.  17  a  (see  Fig.  70).  For  several  teeth  the  long  needle  and 
the  hub  B  or  C  are  employed  (see  Fig.  74).  Again,  the  point  of  inser- 
tion is  compressed  with  the  finger  after  the  injection;  massage  of  the 
injected  portion  is  of  special  advantage  in  the  mandible. 

Lingual  Injection  in  Lower  Molars. — Lingually  the  tooth  to  be  anes- 
thetized is  always  injected  by  way  of  the  cervical  margin  of  the  gin- 
gival tissue,  the  needle  being  advanced  only  as  far  as  the  periosteum 
of  the  alveolar  margin,  where  from  about  10  drops  to  \  c.c.  are  deposited 
in  the  firm  tissue  (see  Fig.  84).  The  syringe  is  mounted  with  middle 
piece  E  and  hub  C,  and  needle  No.  170  (see  Fig.  91),  in  this  way  obtain- 
ing only  a  short  free  needle  point  which  withstands  the  pressure  exerted 
and  does  not  break  easily. 

So  much  for  mucous  anesthesia  in  firm  normal  tissue;  in  spongy 
tissue  the  technique  is  more  difificult,  yet  success  is  insured,  if  the 
periosteum  is  infiltrated. 

Anesthesia  in  Inflammatory  Swelling. — Mucous  Anesthesia-  in  ///- 
flaiiniuitory  Siuelling. — Mention  should  be  made  of  mucous  anesthesia 
in  the  presence  of  parulis  or  alveolar  abscess.  In  such  cases  conduc- 
tive anesthesia  should  always  be  attempted.  If  this  is  unsuccessful 
or  inadvisable,   mucous  anesthesia  alone  is  the  last   and  only  resort. 


168  TECHNIQUE  OF  LOCAL  ANESTHESIA 

Anesthesia  with  Ethyl  Clilorid. — In  the  anterior  teeth,  both  upper 
and  lower,  in  many  cases  the  old  method  of  the  ether  spray  can  be 
employed  with  great  success.  The  diseased  gingival  tissue  is  disin- 
fected with  tincture  of  iodin  and  carefully  dried;  right  and  left  of  the 
swelling  the  alveolar  process  is  padded  with  cotton  rolls  in  order  to 
keep  away  the  saliva  as  much  as  possible,  the  tongue  is  covered  with 
a  small  mouth  napkin,  and  the  ethyl  chlorid  spray  from  an  auto- 
matically closing  flask  is  directed  against  the  mucous  membrane  to  be 
anesthetized,  from  a  distance  of  from  20  to  30  cm.  If  perfectly  dry, 
the  mucosa  is  rapidly  covered  by  a  crust  of  ice  and  congealed.  After 
about  thirty  seconds  the  extraction  can  be  performed,  being  in  most 
cases  painless,  or  at  least  very  tolerable. 

For  the  extraction  of  putrescent  deciduous  teeth  this  method  is 
particularly  practical,  as  the  ether  inhaled  by  the  child  produces  a 
light  narcosis  sufficient  to  render  the  operation  painless.  Ethyl  chlorid 
is  indispensable  also  in  severe  putrescent  conditions,  in  incisions  for 
gum-boils  or  in  extraction  of  loose  putrescent  teeth  or  roots.  In  such 
cases  local  injection  anesthesia  would  be  detrimental  rather  than 
useful,  the  risk  of  infiltrating  an  abscess  or  inflamed  tissue  being  too 
great,  as 'under  certain  conditions  it  involves  general  sepsis  with  possibly 
fatal  results. 

If,  nevertheless,  mucous  anesthesia  is  preferred  to  the  far  more  advis- 
able conductive  anesthesia,  the  injection  should  always  be  made  in  the 
healthy  mucous  membrane  in  the  vicinity  of  the  centre  of  infection 
(see  Figs.  67  and  68).  In  such  cases,  however,  several  injections  on 
either  side  of  the  abscess  must  be  made  into  the  periosteum  only, 
emptying  the  solution  immediately  upon  introducing  the  needle  and 
without  advancing  it. 

Injection  in  Swollen  Areas.  —  Fig.  68  illustrates  the  method  of 
anesthetizing  a  putrescent  upper  lateral  incisor  when  a  swelling  is 
present.  One  injection  is  made  above  the  central  incisor,  the  needle 
pointing  in  the  direction  of  the  root  apex  of  this  tooth.  A  second 
injection  is  made  above  the  gingival  margin  of  the  lateral  incisor,  the 
needle  pointing  distally,  provided  no  abscessed  tissue  is  met  with. 
The  third  and  final  injection  is  made  above  the  canine,   the  needle 


CONDUCTIVE  ANESTHESIA  169 

being  pushed  toward  the  root  apex  of  the  canine.  In  all  these  injec- 
tions, the  needle  is  advanced  directly  to  the  periosteum,  and  the  solu- 
tion is  injected  slowly  and  under  moderate  pressure.  As  soon  as  the 
patient  perceives  a  painful  sensation  of  tension,  injection  at  that  place 
must  be  immediately  discontinued.  If  these  injections  have  been 
successfully  carried  out,  compression  with  the  finger  over  the  places 
of  insertion  is  again  of  the  greatest  value. 

Period  of  Waiting. — In  all  cases  of  mucous  anesthesia,  a  waiting 
period  of  from  eight  to  ten  minutes  must  be  allowed.  Anesthesia  lasts 
from  twenty  to  sixty  minutes. 

Principles  of  Mucous  Anesthesia. — Besides  the  above-mentioned 
cautionary  measures,  such  as  asepsis,  isotonia  of  the  solution,  etc., 
the  following  technically  important  conditions  must  be  fulfilled  to 
insure  the  success  of  mucous  anesthesia: 

1.  Application  of  the  stasis  bandage. 

2.  Thorough  sterilization  with  tincture  of  iodin. 

3.  The  periosteum,  not  the  submucous  tissue,  must  be  infiltrated. 

4.  One  injection   on  each  side  of  the  teeth;  the  fewer  injections, 
the  better  the  effect. 

5.  The  orifice  of  the  sterile  needle  must  always  point  toward  the 
bone. 

6.  Slow,  moderately  strong  pressure  during  the  injection. 

7.  Dosage  and  quantity  of  solution  must  be  gauged  according  to 
each  individual  case. 

8.  Compression  of  the  point  of  injection  with  the  finger  after  with- 
drawing the  needle. 

9.  A  waiting  period  of  from  eight  to  ten  minutes. 
10.  The  patient  to  be  watched  after  the  anesthesia. 

CONDUCTIVE  ANESTHESIA 

If.  an  anesthetizing  solution  is  injected  in  the  vicinity  of  a  fair-sized 
nerve  trunk,  it  penetrates  by  way  of  the  perineurium  into  the  central 
nerve  substance  and  inhibits  its  function,  thereby  paralyzing  the  entire 
peripheral  area  supplied  by  this  nerve.     Upon  blocking  the  conduc- 


170 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


tivity  of  a  certain  nerve  trunk,  sensory  irritations  of  the  terminal 
filaments  are  no  longer  perceived  in  the  central  organ.  "The  sensory 
nerve  tracts  are  easily  and  readily  susceptible  to  nerve  blocking  by 
perineurial  injection,  if  their  minute  terminal  branches  are  inundated 
with  an  anesthetizing"  solution  while  the  interruption  of  conductivity 

Fig.  92 


Syringe  mounted  with  middle  piece  D,  hub  B,  and  needle  No.  17c,  for  injection  at  maxillary 

tuberosity. 

becomes  more  difficult,  ensues  more  slowly  and  requires  a  larger  quan- 
tity and  more  highly  concentrated  solution  of  the  anesthetic,  the  farther 
away  from  the  terminal  distribution  of  the  nerves,  i.  e.,  the  nearer  to 
the  spinal  column  an  injection  is  made."  (Braun.) 

This    contention   is   full}'    borne  out  b}'   practical    experience    with 
anesthesia  of  the  jaws.     The  nerve  terminals  in   the  periosteum   and 


CONDUCTIVE  ANESTIIIiSIA  171 

the  pericementum  are  paralyzed  in  the  shcM'test  and  speediest  wa},' 
by  mucous  anesthesia,  sometimes  within  five  minutes.  Anesthesia 
at  the  maxillary  tuberosity,  which  represents  a  modified  form  of  con- 
ductive anesthesia,  ensues  with  almost  equal  rapidity,  /.  e.,  in  ten 
minutes.  Anesthesia  by  way  of  the  inferior  dental  foramen,  or  man- 
dibular anesthesia,  according  to  the  size  of  the  nerve  trunk  in\ol\ed, 
requires  the  longest  period  of  time,  namely,  twenty  minutes,  since  the 
large  inferior  dental  nerve  must  be  inundated  and  permeated  by  the 
anesthetic. 

Fig.  93 


Position  of  needle  for  injection  at  maxillary  tuberosity.     Needle  yellow. 

For  our  purposes,  the  following  methods  of  conductive  anesthesia  must 
be  considered:  (i)  In  the  maxilla,  {a)  injection  at  the  maxillar\-  tuber- 
osity; (b)  infra-orbital  injection.  (2)  In  the  mandible,  {c)  injection 
in  the  inferior  dental  or  oblique  or  mandibular  foramen,  combined, 
if  necessary,  with  lingual  anesthesia;  {d)  injection  in  the  mental 
foramen. 

Injection  at  the  Maxillary  Tuberosity. — The  Maxillary  Tuberosity. — 
Behind  the  zygomatic  process  and  above  the  root  apices  of  the  upper 
molars,  a  varying  number  of  foramina  is  found  in  the  ab'eolar  process 


172 


TECHNIQUE   OF  LOCAL  ANESTHESIA 


(see  Figs.  26,  48,  52,  and  56).  Through  these  foramina  large  nerve 
branches,  the  posterior  superior  dental  nerves,  enter  the  maxilla,  after 
having  run  for  a  short  distance  with  the  main  trunk,  the  superior 
maxillary  nerve,  on  the  bony  surface  of  the  tuberosity  (see  Figs.  48,  51, 
and  52).  These  nerves  supply  the  three  molars  with  sensory  filaments, 
and  must  therefore  be  blocked  in  order  to  obtain  anesthesia  of  these 
teeth  (see  Fig.  56). 

Fig.  94 


Position  of  needle  for  injection  in  mucous  anesthesia  of  upper  first  molar.     Needle  yellow:    a,  buccal 
injection;  b,  palatal  injection. 

Technique  of  Injection. — In  the  half-open  mouth  the  zygomatic  pro- 
cess is  palpated,  the  cheek  is  drawn  upward,  and  the  long  needle 
No.  17  c,  which  has  been  mounted  upon  the  syringe  with  the  middle 
piece  Z>  and  hub  B  (see  Fig.  92),  is  introduced  high  up  in  the  mucous 
membrane  slightly  laterally  to  the  bone  (see  Fig.  93).  The  needle  is 
then  advanced  with  a  slight  backward  and  upward  inclination  (see 
Fig.  73,  red  arrow  No.  6).  The  syringe  is  held  away  from  the  maxilla, 
while  the  needle  is  kept  as  closely  as  possible  to  the  slightly  convex 
tuberosity   (see   Fig.  93).     When   the  needle,   which  has  a  length  of 


CONIU'CTI  VE  AN ESTIIK.su 


173 


42   mm.,   has   been   inserted   half-way,   al)oul    i    c.c.   of  the  solution   is 
injected  while  pushing  the  needle  into  the  tissues  to  its  full  length. 

To  intensify  the  effect  in  first  molars,  mucous  anesthesia  is  addi- 
tionally produced  buccally  at  about  the  centre  of  the  root  of  the  tooth. 
A  short  needle  is  introduced  into  the  periosteum,  and  an  injecticjn  of 
about  J  c.c.  of  the  solution  is  made,  followed  by  digital  compression 
(see  Fig.  94). 

Fig.  9,5 


Conductive  anesthesia  by  way  of  infra-orbital  foramen. 


Palatally,  the  injection  into  the  mucosa,  as  above  described,  is  made 
at  the  posterior  palatine  foramen  (see  Figs.  80  and  82).  Within  ten 
minutes,  as  a  rule,  complete  anesthesia  of  the  three  upper  molars 
ensues. 


174  TECHNIQUE  OF  LOCAL  ANESTHESIA 

Infra-orbital  Injection. — The  Infra-orbital  Foramen. — The  anterior 
region  of  the  maxilla  is  dominated  by  a  superficial  and  easil}'  reached 
nerve  plexus,  the  anterior  superior  dental  nerves  (see  Figs.  48,  52,  55, 
and  56).  These  are  given  off  from  the  superior  maxillary  nerve  just 
before  its  exit  from  the  infra-orbital  foramen,  and,  entering  a  special 
canal  in  the  anterior  wall  of  the  antrum,  divide  into  a  series  of  branches 
which  supply  the  canine  and  incisor  teeth  (see  Figs.  48  and  52).  In  ■ 
acute  periostitis  and  abscess,  mucous  anesthesia  at  the  root  apex  is 
contraindicated,  as  it  involves  a  risk  of  general  sepsis. 

Technique  of  Infra-orbital  Injection. — Injection  in  the  canine  fossa 
at  the  infra-orbital  foramen  is  invariably  followed  by  the  desired 
result.  The  inferior  margin  of  the  orbit,  below  which  the  anterior 
orifice  of  the  infra-orbital  foramen  is  situated,  is  palpated,  and  the 
tissue  overlying  the  foramen  is  compressed  with  the  thumb  of  the  left 
hand,  at  the  same  time  drawing  the  lip  upward  and  away  from  the  gum 
with  the  third  finger  (see  Fig.  95).  The  infra-orbital  foramen  is  situ- 
ated §  cm.  below  the  lower  margin  of  the  orbit,  almost  exactly  above 
the  first  bicuspid  (see  Figs.  48,  52,  and  73).  The  needle  is  inserted  in  the 
reflection  of  the  mucous  membrane  slightly  posteriorly  to  the  root  apex 
of  the  canine  in  the  mucous  membrane  closely  to  the  lip  muscles,  and 
advanced  obliquely  upward  and  slightly  backward.  As  soon  as  the  long 
needle  No.  17  c,  which  is  mounted  with  the  hub  C  (Fig.  96),  is  felt  below 
the  compressing  finger  tip,  from  0.5  to  I  c.c.  of  the  solution  is  injected. 
After  the  injection  massage  may  be  applied  to  good  advantage. 

This  form  of  injection  requires  a  certain  amount  of  pressure  to  force 
the  solution  through  the  foramen,  since  it  is  not  the  nerve  trunks 
emerging  therefrom,  but  those  situated  more  deeply,  namely,  the 
anterior  superior  dental  nerves,  which  are  to  be  anesthetized.  This 
method,  therefore,  constitutes  an  indirect  form  of  conductive  anesthesia, 
the  solution  having  to  pass  through  the  foramen  in  order  to  become 
effective. 

This  method  is  indicated  only  in  cases  of  acute  abscesses  and  in 
major  operations,  such  as  resection,  when  injection  in  the  infra-orbital 
foramina  on  either  side  proves  most  successful.  In  the  majority  of 
cases,  mucous  anesthesia  at  the  root  apex  of  the  canine  (see  Fig.  76)  or 


CO^'D  UCTI 1  ■£  .1 NES  Til  ESI. 


175 


at  ihf  (Ulterior  nasal  spine  (see  Fig.  jt,)  insures  complete  success,  being 
also  of  easier  execution,  and  invariably  and  prom])th'  effective. 

;  Fig.  go 


Syringe  mounted  with  hub  C  and  needle  No.  i  ye  for  injection  at  infra-orbital  foramen  and 
inferior  mandibular  foramen. 

Palatally,  again,  the  injection  is  not  made  in  the  incisive  papilla ,  which 
would  be  extremely  painful,  but  the  short  needle  No.  ij  a  or  b  is  intro- 
duced parallel  to  the  long  axis  of  the  roots  of  the  teeth  to  be  anesthe- 
tized, injecting  from  8  to  lo  drops,  as  has  been  described  in  detail 
in   the  paragraph   on   mucous  anesthesia   (see   Figs.   69,    "/S,   and   So). 


176  TECHNIQUE  OF  LOCAL  ANESTHESIA 

After  ten  minutes  the  anterior  teeth  on  the  injected  side  are  completely 
anesthetized. 

Injection  in  the  Inferior  Dental  or  Oblique  or  Mandibular  Foramen 
(Mandibular  Injection). — The  Inferior  Dental  or  Mandibular  Foramen. 
— The  inferior  dental  or  oblique  or  mandibular  foramen  in  the  internal 
surface  of  the  ascending  ramus  permits  the  passage  of  the  inferior 
dental  nerve,  which,  with  the  inferior  dental  artery,  passes  forward, 
in  the  dental  canal  of  the  mandible  as  far  as  the  mental  foramen, 
where  it  divides  into  two  terminal  branches,  incisor  and  mental.  For 
the  technique  of  injection  in  the  oblique  foramen  the  relationship  of 
the  body  of  the  jaw  to  the  ascending  ramus  and  that  of  the  muscles 
to  the  foramen  is  of  vital  importance. 

Position  of  the  Syringe. — The  line  of  the  body  of  the  mandible  is  not 
horizontally  continuous  in  a  straight  line  to  the  ascending  ramus,  but 
presents  a  lateral  bulging  at  the  angle,  so  that  the  internal  surface  of 
the  ascending  ramus  is  not  parallel  with  the  lingual  surface  of  the  body 
of  the  jaw  (see  Figs.  36,  83,  and  88).  The  ramus  opens  posteriorly 
(see  Figs.  38,  39,  83,  and  97).  If,  therefore,  the  oblique  foramen  is 
to  be  reached,  we  must  never  advance  posteriorly  parallel  with  the 
teeth  (Figs.  97  and  98),  but  with  the  internal  surface  of  the  ramus, 
at  an  acute  angle  to  the  plane  of  the  teeth  (see  Figs.  38,  97,  98,  and  loi). 
If  the  direction  of  the  ascending  ramus  is  projected  anteriorly,  the  line 
will  meet  the  other  side  in  the  canine  region  between  the  canine  and 
bicuspid  (see  Figs.  38,  39,  97,  98,  and  loi).  Thus  in  order  to  reach  the 
inferior  dental  foramen  the  syringe  must  be  rested  behind  the  canine 
on  the  opposite  side  (see  Figs.  38,  97,  98,  and  loi).  The  foramen  in 
adults  is  situated  at  a  higher  level  than  in  children;  the  horizontal 
direction  of  the  needle  must  therefore  be  modified  in  children  by  slightly 
lowering  it  posteriorly  and  pharyngeally  in  order  to  reach  the  foramen 
directly  (see  Fig.  37,  A,  B,  C). 

Character  of  the  Tissues. — The  character  of  the  tissues  encountered 
is  most  favorable  for  injection  in  the  oblique  foramen.  The  temporal 
and  external  pterygoid  muscles  are  inserted  above,  the  internal  ptery- 
goid below  the  foramen,  leaving  the  close  proximity  of  the  foramen 
free  from  muscular  fibers  (see  Fig.  99).     Instead  we  find  considerable 


COND UCTI VE  ANESTHESIA 


accumulations  of  loose  interstitial  connective  and  adipose  tissue  which 
readily  absorbs  and  retains  the  injected  solution  (see  Fig.  lOo).  This 
cushion  of  tissue  is  situated  about  i  or  2  cm.  above  the  alveolar  process. 

Fig.  97 


Position  of  syringe  for  injection  at  mandibular  foramen:  i  .v,  external  oblique  line;  2  x,  retromolar 
fossa;  3  X,  internal  oblique  line;  4,  mandibular  foramen  behind  lingula;  5,  incorrect  position  of  syringe, 
parallel  to  teeth. 

Technique   of  Injection. — With    the   left   index    finger,    the   anterior 

portion  of  the  base  of  the  ascending  ramus  is  palpated,  the  patient's 

mouth  being  opened  widely.     Two  very  marked  bony  ridges  are  felt 

here,  one  anterior  external,  the  external  oblique  line,  and  one  posterior 

internal,  the  internal  oblique  line  (see  Figs.  38,  39,  97,  98,  and  100). 

Between  these  two  lines  at  the  root  of  the  ascending  ramus  a  shallow 
12 


178 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


bony  groove  is  situated,  which  might  be  properly  called  the  retromolar 
fossa,  into  which  the  palpating  finger  tip  sinks  (see  Figs.  38,  97,  98,  and 
1 01).  The  mucous  membrane  is  caved  in  over  this  fossa  in  somewhat 
triangular  shape;  Braun  therefore  calls  it  the  retromolar  triangle  (see 
Figs.  98  and  100).  The  internal  oblique  line  is  fixed  with  the  finger 
nail,  and  the  needle  inserted  close  to  the  nail  into  the  mucosa  near  to, 
yet  not  immediately  at,  the  edge  of  the  bone  (see  Figs.  38,  97,  and  98)'. 


Lingual  N. 


-    Inferior  dental  iV. 
_  -Inferior  dental  A. 
^..Section  fhroutih  as- 
cending ramus 


■Fetromolar  triangle 


Mucous  covering  {red  line) 
-  ■  ■  Internal  oblique  line 
External  oilique  line 


-Point  of  contact  of  syringe 

n-ith  third  molar 
Third  molar 


""^--^,C'on-ec(  direction  of  needle 
"^Incorrect  directimi  of  needle 
Direction  of  dental  arch 


Horizontal  section  through  ascending  ramus.    Diagram  showing  position  of  syringe  and  needle: 
i,  eminence  of  internal  oblique  line;  e,  eminence  of  external  oblique  line. 


The  syringe  is  pushed  forward  horizontally  and  posteriorly  from  the 
canine  on  the  opposite  side  along  the  internal  surface  of  the  mandibular 
half  to  be  anesthetized  (Figs.  38,  39,  97,  98,  lOi,  and  102),  until  the 
needle  has  disappeared  entirely  (see  Figs.  39  and  98) .  The  needle  should 
be  introduced  to  a  depth  of  not  more  than  from  1.5  to  2  cm.  under  the 
mucosa  (Figs.  39,  97,  and  98),  lest  it  advance  too  far  beyond  the  fora- 
men, and  the  correct  point  for  the  deposition  of  the  solution  be  missed. 


COSD  rCTI  VE  AXESTHESI. 


179 


It  is  best  to  mount  the  syringe  with  the  hub  C  and  the  needle  No.  17  c 
(Fig.  96),  so  that  from  3  to  5  cm.  of  the  needle  remain  visible  above  the 
mucosa  (see  Figs.  39,  97,  and  98),  when  failure  to  reach  the  correct 
point  for  injection  is  hardly  to  be  feared.  The  injecting  solution  is  then 
deposited,  beginning  to  inject  soon  after  insertion  of  the  needle  in  order 
to  anesthetize  the  lingual  nerve  at  the  same  time.  The  bulk  of  the 
solution,  however,  should  be  injected  in  the  mandibular  foramen. 

Insertion  of  the  Needle. — The  point  of  injection  is  selected  so  that 
the  needle  is  introduced  in  the  mucous  triangle  about  i  cm.  above  the 
■level  of  the  masticating  surfaces  of  the  molars  (Figs.  97,  98,  99,  100, 


Fig.  99 


Eitei  nnl  ptei  i/qoid  M 


Genio-glossus  M     r—^ 
Geniohyoid  M  -L  ' 


I)iqast>ic  M        Vi/l    In/  iil  II 
Origins  and  insertions  of  muscles  upon  inner  surface  of  mandible.     (From  Rauber  and  Kopsch.) 


and  104),  in  children  and  youthful  persons  advancing  a  little  farther 
posteriorly  while  slightly  lowering  the  needle,  in  old  persons  slightly 
raising  the  long  needle  (see  Fig.  37).  Besides,  in  the  buccal  mucosa 
near  the  cervical  margin  of  the  gingiva  of  the  teeth  to  be  anesthetized 
about  f  c.c.  of  the  solution  is  injected,  thereby  combining  conductive 
with  mucous  anesthesia.  In  adults  after  about  twenty  minutes,  in 
children  after  from  ten  to  fifteen  minutes,  as  a  rule,  every  tooth  in- 
cluding the  first  bicuspid  is  anesthetized. 

The  syringe  is  mounted   with  the  hub  C  and   the  needle  No.    17c 
(see  Fig.  96). 


180 


TECHXIQUE  OF  LOCAL  ANESTHESIA 


Difficulties. — The  technique  of  this  form  of  injection  offers  some 
difficulties  which,  however,  after  some  practice  are  easily  overcome. 
i\bove  all  it  must  be  observed  that  the  insertion  of  the  needle  is  made 
not  directh'  at  the  edge  of  the  bone  in  the  inteynal  oblique  line,  but 


Occipito-frontal  M 
Aponeta  osis 


Zygomatic  at cli~T'     \*v     i 
Parotid  almtd 'J 


Massetei  M  — 


•^1    \        ^ — External  pienigoid  M. 

Lateral  plate  of  ptery- 
qoid  process 
idipose  tissue 

Internal  pterygoid  M. 
Mandible 


Frontal  section  of  temporal  region.  The  black  line  indicates  the  aponeurosis,  the  blue  line  the 
periosteum  and  temporal  fascia.  At  the  mandibular  foramen  a  mass  of  adipose  tissue  is  observed 
which  offers  no  resistance  to  the  advance  of  the  needle.     (From  Merkel.) 


somewhat  lingually  from  the  bone  (see  Figs.  38,  97,  and  98).  Behind  this 
internal  ridge  the  bony  substance  bulges  still  farther  lingually,  running 
over  into  the  lingula,  after  having  first  formed  a  second  convex  excres- 
cence (see  Figs.  39,  97,  and  98).     After  the  correct  point  of  insertion. 


CO.\DLTTI]-E  .WEST  11  ESI  A 


181 


about   I    cm.   above  the  level  of  the   masticating  surface  of  the  last 
molar,  has  been  found,  the  oblique  foramen  is  reached  just  above  the 


TT^ 


..-'^%^ 


t-:-:. 


^ 

Freuum 

liibii  superioris 

Ik''' 

iifiiva 

&..'- 

Upper  lip 

;   1 

^,--  Cpper  dental  arch 

i 

%^1 

__'-   Hard  palate 

C 

m 

i 

Wk^-  Soft  palate 

t  m\f{ 

^■^  Uvula 

rFJ 

^^m  Anterior  pillars 

l>li"^ 

^^/b  Posteriur  pillars 

K:r"j 

^m.To„sii 

W/f;'M 

tB>-^Point  of   insertion   of 

^ifl 

IV         needle  in  retromolar 
H           fossa 

? 

i 

'     ^^  Isthmus 

f 

"^  Tongue 

M 

Cnl  portion  of  cheek 

r^-- 

^            ^  Loiver  dental  arch 

^   f^innJ 

Lrntgi 

la 

Frenmn 

labii  inferioris 

Lo 

wer  lip 

Oral  cavity,  widely  opened.  The  dotted  red  line  indicates  the  correct  position  of  the  syringe  for 
mandibular  anesthesia.  The  red  arrows  at  the  anterior  portion  of  the  mandible  indicate  the  points 
of  insertion  of  the  needle  in  the  reflection  of  mucous  membrane  for  injection  in  canine  fossa.  (After 
Spalteholz.) 

lingula  with  the  needle  No.  17  c  and  the  hub  C  (see  Figs.  39,  97,  and  98). 
The  distance  from  the  anterior  margin  of  the  internal  oblique  line  to 
the  posterior  margin  of  the  lingula  is  about  15  mm.,  while  the  needle 


182 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


No.  17  c  protrudes  25  mm.  from  the  hub  C  (Figs.  39,  97,  and  98),  so 
that  the  needle  has  the  correct  practical  length  for  passing  through 
the  mucous  layer  (which  is  not  seen  in  the  illustrations  of  skulls)  and 
for  reaching  from  about  5  to  8  mm.  beyond  the  lingula  (see  Figs.  39, 
97,  and  98).  It  is  not  advisable  to  use  the  full  length  of  the  needle, 
which  is  42  mm.,  as  one  might  penetrate  too  far  posteriorly,  thereby 
missing  the  point  most  favorable  for  the  deposition  of  the  solution 
(see  Figs.  39,  97,  and  98).     During  the  injection  it  is  best,  as  has  been 


Position  of  syringe  for  injection  in  mandibular  foramen  and  palpation  of  retromolar  triangle.    Syringe 
is  held  like  a  penholder. 

correctly  emphasized  by  Williger,  to  rest  the  syringe  barrel  on  the 
bicuspid  or  between  the  canine  and  first  bicuspid  of  the  opposite  side, 
thus  securing  a  certain  support  for  the  syringe  and  an  indication  for 
the  correct  level  for  the  insertion  of  the  needle  (see  Figs.  38,  39,  97, 
loi,  and  102). 

Management  of  the  Needle. — After  insertion,  the  needle  is  advanced 
to  the  bone  without  entering  the  periosteum  (see  Figs.  97  and  98). 
A  certain  touch   is  soon  acquired  as  to  whether  the  needle  is  being 


CONDUCTl  VE   ANESTHESIA 


183 


acK-anced  in  the  correct  direction,  not  too  far  pharyngeally,  \'et  closeh' 
enough  to  the  bone.  If,  in  case  of  a  very  sharp  angle  of  the  bone,  the 
periosteum  is  found  to  ofifer  resistance,  even  though  moderately,  the 
needle  should  not  be  advanced  any  farther,  and  under  no  condition 
by  force,  else  the  needle  bores  into  the  periosteum  of  the  bone  and  is 

Fig.   103 


Position  of  syringe  during  injection  in  mandibular  foramen.    The  finger  of  the  left  hand  rests 
in  the  retromolar  fossa. 


sure  to  break.  It  is  best  to  carefully  withdraw  the  needle  for  a  short 
distance,  and  after  slightly  altering  its  direction  pharyngeal!}-  to  ad- 
vance again  posteriorly.  The  bone  should  not  be  reached  before  the 
needle  has  gone  for  a  certain  distance  from  the  point  of  introduction 
(Figs.  39,  97,  and  98),  yet  not  immediately  at  the  internal  oblique  line. 


184 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


as  has  already  been  demonstrated.    The  needle  has  reached  a  sufficient 
depth  when  5  mm.  of  its  length  remains  visible. 

Injection  of  the  Solution. — The  solution  should  be  emptied  slowly 
and  carefully,  beginning  immediately  upon  insertion  of  the  needle,  in 
order  to  anesthetize  simultaneously  the  lingual  nerve,  which  descends 
in  front  of  the  inferior  dental  nerve  (see  Figs.  49  and  60).     The  bulk 


Fig.  104 

Glosso-phaii/iHieal  X. 

rotid  nrtrrji  and  pneumorjastric  N. 

^rririi!  iiinniHun  tif  superior  si/uipathetic  iriinh 


Interna}  < 


Internal  jugular  vein  and 
glosso-pharyngeal  N. 

Parotid  fascia 

Posterior  facial  rein 

External  carotid  A.. 
Parotid  gland. 

Facial  N.. 


Inferior  dental  arteri/ and  nerrC' 
Mandible 


-Atlas  u-itli  prerertebral  fascia 


Rectus  eapiiis  anticus  m 
Qf-^^K  and  longus  colli  Mm. 


Hi/poglossal  N. 


\    Tonsil 
Internal  maxillary  artery  and  vein 
Internal  pteritiioid  M. 

Horizontal  section  through  lower  portion  of  oral  cavity.  Relationship  of  lower  teeth  to  ascending 
ramus  and  mandibular  foramen.  Red  arrow  indicates  the  correct  position  of  syringe  and  needle 
for  mandibular  injection.     (Corning.) 


of  the  solution,  however,  is  deposited  at  the  oblique  foramen.  The 
adipose  and  loose  connective  tissues  overlying  this  foramen  readily 
absorb  the  solution  without  any  pain  to  the  patient  (see  Fig.  100). 
Penetration  of  the  muscles  in  this  region  is  out  of  the  question,  as  has 
been  shown  above  (see  Figs.  99  and  100).  Neither  is  there  any  danger 
of  puncturing  the  artery,  which  possesses  thick  walls,  is  protected  by 


COND  UCTI VE  A NES TIIESIA 


185 


tlic  lingula  and  has  enough  space  to  evade  into  the  loose  surrounding 
tissues  or  into  the  depth  of  the  inferior  dental  canal  (see  Fig.  98). 
The  corresponding  vein  is  arranged  around  the  artery  in  form  of  an 

Fig.   105 

Conilimt.  aiiesth.  hy  way  of 
'    infra-urbilul  foramen 


Conduct,  anesth.  by  way  of 
•  1      maxillary  tnherosify 


Manilihidar  foraii 


Conduct,  anesth.  by  way  of 
mandibular  foramen 


Conduct,  aneslh.  hy  way  of  canine  fossa 


Miicou 


Conduct  ire  anestliciia 

Diagram  illustrating  the  technique  and  dosage  for  local  injection  anesthesia.  On  the  left,  black 
figures  indicate  technique  and  dosage  for  mucous  anesthesia.  On  the  right,  red  figures  indicate  tech- 
nique and  dosage  for  conductive  anesthesia.  Dosage:  i  =  about  lo  drops;  2  =  0.25  c.c;  3  = 
0.5  c.c;  4  =  1  c.c;  5  =  1.25  c.c;  6  =  1.5  c.c;  7=2  c.c.  In  the  maxilla  conductive  anesthesia  by 
way  of  the  infra-orbital  foramen  and  the  maxillary  tuberosity  involves  the  entire  half  of  the  jaw, 
including  the  bicuspids. 


186  TECHNIQUE  OF  LOCAL  ANESTHESIA 

intricate  plexus,  and  is  equally  well  protected.  Moreover  it  is  extremely 
difficult  to  puncture  an  arterial  wall,  even  to  cut  it  with  a  sharp  knife, 
as,  owing  to  its  elasticity,  it  always  has  the  tendency  to  escape. 

The  injection  in  the  left  ramus  offers  somewhat  greater  difficulties. 
While  in  the  right  oblique  foramen  the  retromolar  triangle  is  palpated 
with  the  left  hand,  and  the  injection  is  made  with  the  right,  it  is 
advisable  to  use  the  left  hand  for  injection  on  the  left  side,  according 
to  Peckert's  suggestion,  palpating  and  fixing  the  retromolar  triangle 
with  the  right. 

Effect  of  the  Injection. — About  three  minutes  after  the  injection 
the  patient  perceives  a  slight  tingling  in  the  lip  and  tongue  on  the 
injected  side.  This  tingling  is  the  best  indication  as  to  the  correct 
execution  of  the  injection.  This  sensation  gradually  increases,  and  a 
certain  numbness  of  the  entire  half  of  the  jaw  ensues,  so  that  the  con- 
tact of  the  rinsing  glass  with  the  anesthetized  lip  is  no  longer  felt. 
The  patients  have  a  sensation  as  if  the  margin  of  the  glass  were  cut  in 
semilunar  shape.  The  lip  on  the  anesthetized  side  depends  slightly, 
exhibiting  symptoms  of  partial  paralysis,  and  the  patient  usually  feels 
as  if  it  were  greatly  swollen.  Difficult  deglutition  is  absent  if  the 
technique  has  been  executed  correctly.  Its  presence  indicates  that  the 
injection  has  been  made  too  far  pharyngeally  and  posteriorly.  The 
concomitant  symptoms  persist  for  about  one  hour,  after  which  they 
gradually  subside,  the  former  normal  condition  being  reestablished 
after  about  three  hours. 

Paralyzation  of  the  Buccal  Nerve. — As  has  been  pointed  out  before, 
it  is  necessary  to  make  an  injection  in  the  buccal  mucosa  at  the  lower 
molars  and  bicuspids  in  order  to  anesthetize  the  buccal  nerve,  which 
is  distributed  over  the  region  of  the  second  and  first  molars  and  the 
second  bicuspid  (see  Figs.  55  and  59).  Williger  recommends  for  this 
purpose  an  injection  in  the  mucous  membrane  of  the  cheek  below 
Stenson's  duct,  whereby  "absolute  insensibility  of  the  mandible  and 
its  cover  of  soft  tissues  is  produced."  This  method  of  Williger  is 
highly  to  be  commended  in  cases  associated  with  inflammatory  symp- 
toms in  the  bicuspid  and  molar  regions. 

Mandibular   anesthesia   is   not  concerned   with   periosteal   injection 


CONDUCTIVE  AX  EST  II  ESI  A  187 

as  much  as  is  nuicous  anesthesia,  but  has  the  sole  puri:)ose  of  making  a 
deposit  of  solution  in  the  environment  of  a  large  nerve  trunk.  For  this 
reason  conductive  anesthesia  calls  for  no  pressure,  which,  to  a  moderate 
degree  at  least,  plays  a  role  in  every  periosteal  injection. 

Injection  in  the  Mental  Foramen. — As  in  the  case  of  infra-orbital 
injection,  the  method  of  producing  anesthesia  by  way  of  the  mental 
foramen  consists  in  making  an  injection  under  moderate  pressure  and 
forcing  the  solution  through  this  large  foramen  into  the  inferior  dental 
canal.  Buente  and  Moral  advocate  mental  anesthesia,  which  has  been 
indicated  also  by  Braun  and  Schleich,  for  paralyzation  of  the  anasto- 
mosis with  the  opposite  side. 

The  Purpose  of  Injection  in  the  Mental  Foramen. — "While  Schleich 
anesthetizes  the  mental  nerve  on  the  side  on  which  he  wishes  to  oper- 
ate, we  introduce  the  anesthetic  in  the  mental  foramen  of  the  opposite 
side  as  has  been  previously  suggested  by  Peckert.  After  careful  ex- 
periments and  observations  in  patients,  we  may  assume  with  a  fair 
degree  of  certainty  that  the  sphere  of  the  anastomosis  does  not  ex- 
tend beyond  the  canine  of  the  opposite  side.  When  the  entire  anterior 
portion  was  to  be  anesthetized,  we  have  inundated  both  foramina  with 
the  anesthetic  solution."  (Buente  and  Moral.)  In  such  cases  it  sufifices, 
however,  to  inject  labially  in  the  me^ital  fossce  on  either  side  (Figs.  83 
and  86),  and  lingually  between  the  canine  and  bicuspid  on  either  side 
in  order  to  anesthetize  the  lingual  nerves  (see  Fig.  89). 

Technique  of  Injection. — The  mental  foramen  is  situated,  as  a  rule, 
between  the  first  and  second  bicuspids  at  the  base  of  the  alveolar 
process,  below  the  root  apices  of  the  bicuspids  (see  Figs.  19  to  25,  55, 
59,  and  83).  The  needle  is  introduced  in  the  reflection  of  the  mucous 
membrane  below  the  second  bicuspid,  penetrating  the  periosteum  while 
slowly  injecting  and  pushing  downward  on  the  bone  for  several  milli- 
meters. About  I  c.c.  of  the  solution  is  injected,  and  the  point  ot  inser- 
tion is  compressed  with  the  finger  after  the  injection.  The  syringe  is 
mounted  with  hub  B  and  needle  No.  170  (see  Figs.  70  and  90). 

Anesthetization  of  the  Opposite  Side. — Anesthesia  by  way  of  the 
mental  foramen  is  important  abo\'e  all  as  an  accessor}-,  as  it  can 
be   advantageously  employed    for  paralyzing  the  anastomosis  of    the 


188  TECHNIQUE  OF  LOCAL  ANESTHESIA 

opposite  side  as  well  as  for  anesthesia  of  the  entire  anterior  portion  of 
the  mandible.  Occasionally  this  method  renders  good  service  in  mucous 
anesthesia  of  the  bicuspids.  Its  main  value,  however,  on  the  principle 
of  conductive  anesthesia,  consists  in  abolishing  sensibility  of  the  deli- 
cate nerve  filaments  radiating  beyond  the  median  line  to  the  opposite 
side.  To  recapitulate:  If  the  right  side  of  the  mandible  up  to  the  sym- 
physis is  to  be  anesthetized,  injections  are  made  in  the  right  inferior 
dental  foramen  and  the  left  mental  foramen,  moreover  lingually 
behind  the  left  canine,  the  right  lingual  nerve  branch  being  paralyzed 
by  the  first  injection. 

Principles  of  Conductive  Anesthesia. — i.  Application  of  the  stasis 
bandage. 

2.  Thorough  sterilization  with  tincture  of  iodin. 

3.  Infiltration  of  the  perineurial  tissue. 

4.  Only  one  insertion  of  the  needle.  Insertion  at  the  incisive  fora- 
men to  be  avoided. 

5.  The  orifice  of  the  sterile  needle  must  always  point  toward  the  bone. 

6.  The  solution  is  emptied  during  insertion  of  the  needle  under 
cautious  pressure. 

7.  Dosage  and  quantity  of  solution  must  be  gauged  according  to  each 
individual  case. 

8.  In  the  posterior  palatine  foramen  only  from  8  to  10  drops  should 
be  injected. 

9.  For  injection  at  the  maxillary  tuberosity  the  zygomatic  process 
is  palpated;  the  needle  is  inserted  in  the  mucous  membrane  behind 
the  process;  the  needle  of  42  mm.  length  mounted  with  hubs  B  and  D 
is  only  gradually  advanced  to  the  convexity  of  the  tuberosity,  the 
syringe  being  held  away  from  the  bone  at  an  acute  angle,  and  the 
needle  being  advanced  upward  and  slightly  posteriorly  in  the  direc- 
tion of  the  temple. 

10.  In  mandibular  anesthesia,  i.  e.,  injection  in  the  inferior  dental 
or  oblique  foramen,  the  retromolar  triangle  is  palpated,  allowing  the 
finger  tip  to  rest  therein;  the  needle  is  inserted  i  cm.  above  the  level 
of  the  masticating  surfaces  of  the  molars,  and  from  3  to  5  mm.  laterally 
from  the  internal  oblique  line  of  the  ascending  ramus;  the  syringe  is 


EXTENT  OF  ANESTHESIA   OBTAINED  189 

mounted  with  hub  C  and  needle  No.  17c  and  rested  upon  the  first 
bicuspid  or  canine  of  the  opposite  side.  The  needle  is  advanced  pos- 
teriorly and  outwardly,  in  adults  straight,  in  children  slightly  inclined, 
until  only  5  mm.  of  its  length  remains  visible;  the  bone  is  reached  not 
immediately,  but  some  distance  from  the  point  of  insertion  of  the  needle, 
about  half  of  its  inserted  length. 

11.  A  waiting  period  of  ten  minutes;  after  injection  in  the  inferior 
dental  foramen,  twenty  minutes. 

12.  The  patient  to  be  watched  after  the  anesthesia. 

EXTENT    OF   ANESTHESIA    OBTAINED 

The  action  of  local  anesthetics  in  the  healthy  organism  can  be  traced 
step  by  step,  especially  with  the  aid  of  the  electric  current. 

Completion  of  Anesthesia  in  the  Maxilla. — In  mucous  anesthesia 
of  the  upper  central  incisor,  a  diminution  in  the  sensibility  of  the  pulp 
is  noted  after  two  minutes,  gradually  decreasing,  until  after  five  min- 
utes complete  anesthesia  is  established.  This  condition  of  complete 
anesthesia  usually  lasts  from  twenty  to  twenty-five  minutes.  It  is 
notew^orthy  that,  even  during  this  state  of  complete  paralysis,  strong 
electric  currents  still  exert  an  influence  upon  the  eye,  sometimes  pro- 
ducing a  slight  oscillation  as  well  as  lacrimal  secretion,  owing  to  the 
relations  to  the  first  trigeminal  division  (see  p.  126,  and  Figs.  48,  49, 
and  51).  After  about  seventy  minutes,  counting  from  the  beginning 
of  the  injection,  normal  conditions  were  reestablished  in  the  cases 
examined. 

Anesthesia  in  the  Region  of  the  Maxillary  Tuberosity. — After  in- 
jection at  the  maxillary  tuberosity  and  in  the  posterior  palatine  fora- 
men, sensibility  is  reduced  in  all  molars  and  bicuspids  after  two  minutes; 
after  five  minutes  the  canine  also  exhibits  reduced  sensibility.  After 
three  additional  minutes  the  buccal  mucous  membrane  is  entirely  in- 
sensible, while  the  lip  seems  still  to  react  normally.  Within  ten  minutes 
complete  anesthesia  is  established  in  all  molars,  lasting  for  over  ten 
minutes,  then  gradually  subsiding.  The  sensibility  of  the  bicuspids 
and  canines  is  notably  reduced.     Within  from  thirty  to  forty  minutes. 


190  TECHNIQUE  OF  LOCAL  ANESTHESIA 

normal  irritability  is  reestablished  in  the  individual  teeth,  while  the 
mucosa,  especially  in  the  vicinity  of  the  maxillary  tuberosity,  remains 
completely  anesthetized. 

The  prompt  effect  of  injection  at  the  maxillary  tuberosity  was 
demonstrated  in  a  highly  sensitive  and  seriously  neurotic  woman. 
Anesthesia  of  the  second  upper  bicuspid  with  an  inflamed  pulp  was 
accompanied  by  the  following  symptoms:  After  two  minutes  light 
anesthesia  set  in  in  all  molars  and  bicuspids  of  the  injected  side.  After 
three  minutes  the  teeth,  which  had  been  extremely  sensitive  to  a  light 
current,  tolerated  a  current  of  double,  after  five  minutes  one  of  triple 
strength.  After  fourteen  minutes  complete  anesthesia  was  established. 
The  pulp  of  the  second  bicuspid  was  amputated  to  the  root  canals 
without  any  pain  whatever.  For  the  sake  of  experiment,  the  strong 
current  was  applied  to  the  amputated  pulp  stumps.  It  was  surprising 
to  note  a  very  faint  reflex.  Nevertheless,  the  root  portions  of  the  pulp 
were  immediately  extirpated,  without  any  pain  whatever,  contrary 
to  expectation.  The  mechanical  irritation  inherent  to  extirpation 
of  the  pulp  produced  no  pain,  Avhile  electric  irritation  was  still  per- 
ceived, presumably  because,  in  contradistinction  to  the  irritation  from 
localized  pressure,  it  was  conveyed  intracellularly  to  remote  areas. 
After  twenty-six  minutes  the  anesthesia  began  to  wear  off. 

Anesthesia  in  the  Region  of  the  Infra-orbital  Foramen. — At  the 
infra-orbital  foramen  the  injection  produced  a  pronounced  anesthe- 
tization of  the  superficial  mucous  and  muscular  layers  (Fig.  51),  char- 
acterized by  a  reduction  in  sensibility  within  one  minute.  The  anterior 
teeth  were  completely  anesthetized  after  eleven  minutes,  sensibility^ 
gradually  returning  after  twenty-five  minutes. 

Anesthesia  in  the  Mandible. — The  action  of  mucous  anesthesia  in 
the  mandible  appears  to  be  rather  less  favorable.  This  form  of  anes- 
thesia was  applied  to  a  lower  first  bicuspid  aff^ected  with  pulpitis,  the 
sensibility  of  the  pulp  not  being  notably  reduced  even  after  eight  minutes. 
Anesthesia  by  way  of  the  inferior  dental  foramen  was  thereupon  imme- 
diately induced,  and  within  three  minutes  the  sensibility  of  the  pul- 
pitic  tooth  was  considerably  reduced,  complete  analgesia  ensuing  within 
fourteen  minutes  from  the  beginning  of  the  experiment. 


TABLES   FOR  INJECTION  ANESTHESIA  191 

Anesthesia  by  Way  of  the  Inferior  Dental  Foramen. — In  another 
case  it  was  observed  that  within  three  minutes  after  injection  in  the 
inferior  dental  foramen  anesthesia  of  the  corner  of  the  mouth  and  the 
mucosa  of  the  lip  was  established.  After  four  minutes  tingling  in  the 
lip  and  in  the  anesthetized  half  of  the  tongue  was  perceived.  The  tongue 
grew  heavier  every  minute,  and  the  numbness  of  the  lip  spread  to  the 
other  side.  After  ten  minutes  the  teeth  in  one-half  of  the  mandible 
with  the  exception  of  the  second  molar  and  the  canine  were  insensible, 
and  within  twenty-three  minutes  altogether  the  entire  half  of  the  jaw- 
was  anesthetized.  Complete  anesthesia  with  all  its  symptoms  per- 
sisted for  twenty-five  minutes,  when  it  gradually  subsided.  The 
central  incisors  were  the  first  to  regain  sensibility,  followed  in  rapid 
succession  by  the  remainder  of  the  teeth.  The  tongue  had  become 
normal  after  ninety-seven  minutes,  w'hile  the  mucosa  remained  insensible 
even  after  one  hundred  and  twenty-five  minutes,  and  normal  sensibility 
was  not  reestablished  until  three  hours  after  injection. 

TABLES   FOR  INJECTION  ANESTHESIA 

In  order  to  avoid  repetitions  such  as  the  histories  of  a  series  of 
practical  cases  would  entail,  and  at  the  same  time  to  afford  a  practical 
working  scheme  for  the  application  of  the  methods  described,  tables  are 
here  presented  which  indicate  the  method  of  injection  best  suited  for 
each  individual  tooth.  Consideration  of  the  practical  requirements  of 
each  special  case  may,  of  course,  call  for  modifications  of  these  tables, 
which  are  intended  to  be  a  general  guide  to  those  who  intend  to  become 
practical  experts  in  this  somewhat  difificult  technique. 

After  some  practice  and  experience,  the  methods  of  local  anesthesia 
which  have  been  demonstrated  can  be  perfectly  mastered  by  every 
operator,  and  will  materially  enhance  the  efficiency  of  his  work  and 
prove  a  boon  to  his  patients. 


192 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


Teeth. 
I.  Upper. 


Technique  of  injection  employed. 


(a)  in  simple  cases. 


(b)  in  cases  complicated 
by  periostitis,  parulis, 
etc. 


Mountings 

of 

syringe. 


Quantity  of  solution 

in  labial  in  palatal 
or  buccal  or  lingual 
injections,  injections. 


I.  Central 
incisors. 


Lateral 
incisors. 


3.  Canines. 


4.  First 
bicuspids. 


5.  Second 
.  bicuspids. 


6.  First 
molars. 


Needle  inserted  at  root 
centre  of  lateral,  and 
directed  to  root  apex 
of  central.  Palatally, 
injection  at  central. 


Needle  inserted  at  root 
centre  of  canine,  and 
directed  to  root  apex 
of  lateral.  Palatally, 
injection  of  lateral. 


Needle  inserted  back  of 
root  apex  of  canine, 
where  some  solution  is 
deposited,  and  directed 
toward  canine.  Pala- 
tally, injection  at  the 
canine. 

Needle  inserted  in  cen- 
tre of  canine,  and  di- 
rected to  root  apex  of 
first  bicuspid.  Pala- 
tally, injection  at  first 
bicuspid. 


.Needle  inserted  in  cen- 
tre of  first  bicuspid 
and  directed  to  root 
apex  of  second  bicus- 
pid. Palatally,  injec- 
tion at  second  bicus- 
pid. 

Injections  at  maxillary 
tuberosity  and  root 
centre  of  first  molar. 
Palatally,  injection  at 
posterior  palatine  fora- 
men. 


Needle  inserted  at  root 
centres  of  canine,  and 
central  of  opposite  side, 
whose  root  apices  are 
infiltrated  with  solu- 
tion. Palatally,  injec- 
tions at  lateral ,  and  cen- 
tral of  opposite  side,  or 
conductive  anesthesia 
from  infra-orbital  fora- 
men, and  mucous  anes- 
thesia at  central  of 
opposite  side,  palat- 
ally. 

Needle  inserted  back  of 
root  apex  of  canine, 
where  solution  is  de- 
posited; same  proced- 
ure at  root  apex  of 
central.  Palatally,  in- 
jection at  lateral,  or  at 
central  and  canine. 

Conductive  anesthesia 
from  infra-orbital  fora- 
men. Palatally,  injec- 
tion at  canine,  or  first 
bicuspid  and  lateral. 


Conductive  anesthesia 
from  infra-orbital  fora- 
men, or  injections  at 
root  apices  of  canine 
and  second  bicuspid. 
Palatally,  injection  at 
first  bicuspid, or  second 
bicuspid  and  canine. 

Conductive  anesthesia 
from  infra-orbital  fora- 
men, and  injection  at 
maxillary  tuberosity. 
Palatally,  injection  at 
second  bicuspid  and 
posterior  palatine  fora- 
men. 

Injection  at  maxillary 
tuberosity  and  infra- 
orbital foramen.  Palat- 
ally, injection  at  poste- 
rior palatine  foramen. 


HubsBorC. 

Needle  No. 
17a. 

For  conduc- 
tive anes- 
t  h  e  s  i  a, 
needle  No. 
17  c. 


As  in  I. 


(a)  As  in  I , 

(b)  Long 
needle  No. 
17c. 


(a)  As  in  i. 

(b)  As  in  3. 


(a)  As  in  i. 

(b)  As  in  3. 


(a)  and  (b) 
Hub  B 
and  needle 
No.  17  c;  if 
desirable 
in  injection 
at  maxil- 
lary tuber- 
osity, mid- 
dle piece  Dj. 


In  cases  of  class, 
(a)  0.5  c.c.  (a)  0.1  c.c. 


(b)  l.o  c.c. 


(b)  0.3  c.c. 
(See  Fig. 
81.) 


(a)  0.5  c.c.  (a)  0.1  c.c. 

(b)  i.oc.c.  (b)  0.3  c.c. 


(a)  I.oc.c.  j(a)  0.5  c.c. 

(b)  1.5  c.c.  (b)  0.5  c.c. 
(See    Fig. 

76.) 


(a)  I.oc.c. 

(b)  1.5  c.c. 


(a)  1.5  c.c. 

(b)  2.0  c.c. 


(a)  1.5  c.c. 

(b)  about 
10  drops. 


(a)  0.5  c.c. 

(b)  0.5  c.c. 
(See  Fig. 

77.) 


(a)o.50  c.c. 
(b)o.25c.c. 


(a)o.25c.c. 
(b)  about 

ID  drops. 
(See  Fig. 

94-) 


TABLES   FOR  INJECTION  ANESTHESIA 


193 


Teeth. 
I.  Upper. 


Second 
molars. 


Third 
molars. 


IL  Lower. 


9.  Central 
incisors. 


Teclinit|ue  of  injection  employed, 
(a)  in  simple  cases. 


(b)  in  cases  complicated 

by  periostitis,  parulis, 

etc. 


Mountings 
of 


Quantity  of  solution 


Injection  at  maxillary 
tuberosity  and  root 
centre  of  second  molar. 
Palatally,  injection  at 
posterior  palatine  fora- 
men. 

Injection  at  maxillary 
tuberosity  and  root 
centre  of  third  molar. 
Palatally,  injection  at 
posterior  palatine  fora- 
men. 


Needle  inserted  at  root 
centre  of  lateral,  and 
directed  to  root  apex 
of  central.  Lingually, 
injection  at  central. 


Needle  inserted  at  root 
centre  of  canine,  and 
directed  to  lateral. 
Lingually,  injection  at 
lateral. 


II.  Canines  Needle  inserted  at  re- 
flection of  mucous 
membrane  below  ca- 
nine, and  directed  to 
mental  fossa,  where 
I    solution   is   deposited. 

•  Lingually,  injection  at 

•  canine  or  first  bicuspid, 
or  conductive  anesthe- 

I    sia    from    mandibular 
foramen. 

Needle  inserted  in  gin- 
gival papilla  of  canine, 
and  directed  horizon- 
tally to  first  bicuspid. 
Lingually,  injection  at 
first  bicuspid,  or  con- 
ductive anesthesia 
from  mandibular  fora- 


10.   Lateral 
incisors. 


12.  First     j 
bicuspids.! 


Injection  at  maxillary 
tuberosity  and  infra- 
orbital foramen.  Palat- 
ally, injection  at  poste- 
rior palatine  foramen. 

Injection  at  maxillary 
tuberosity.  Palatally, 
injection  at  posterior 
palatine  foramen. 


Needle  inserted  at  re- 
flection of  mucous 
membrane  below  cen- 
tral, and  directed  to 
mental  fossa,  where 
solution  is  deposited. 
Lingually,  injection  at 
lateral. 


Needle  inserted  at  re- 
flection of  mucous 
membrane  below  ca- 
nine, and  directed  to 
mental  fossa,  where 
solution  is  deposited. 
Lingually,  injection  at 
canine. 

Needle  inserted  at  re- 
flection of  mucous 
membrane,  below  ca- 
nine, and  directed  to 
mental  fossa,  where 
solution  is  deposited. 
Conductive  anesthesia 
from  mandibular  fora- 
men. Lingually,  injec- 
tion at  first  bicuspid. 

Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccal!  y  in  papilla  of 
first  bicuspid.  Lin- 
gually, injection  at 
second  bicuspid. 


in  labial     in  palatal 
syringe.         or  buccal    or  lingual 
injections,   injections. 


As  in  6. 


(a)  Hub  B 
and  needle 
No.  17  a. 

(b)  Hub  C 
and  needle 
No.  17  c. 

Palatally,al- 
ways  mid- 
dle piece  E 
and  needle 
No.  17  a. 

(a)  As  in  9. 

(b)  As  in  9. 


(a)  and  (b) 
Hub  C  and 
needle  No. 
17  c. 

Lingually, 
Hub  E  and 
needle  No. 
17a. 


(a)  Hub  B 
and  needle 
No.  17  a. 

(b)  Hub  B 
or  C  and 
needle  No. 
17c. 

Lingually, 
middle  piece 
E  and  needle 
No.  17  a. 


As  in  6. 
(See  Fig. 
93-) 


(a)  0.6  c.c.  ,(a)o.25c.c. 

(b)  i.oc.c.  (b)o.25c.c. 


(a)  0.6  c.c. 


(a)o.25  c.c. 


(b)  I.oc.c.  i(b)o.25c.c. 


(a)  I.oc.c.   (a)o.25cc. 

(b)  2.0  c.c.  (b)o.25c.c. 

(See     Fig. 
87.) 


(a)  I.oc.c.   (a)o.25c.c. 

(b)  2.5  c.c.  (b)o.25c.c. 


194 


TECHNIQUE  OF  LOCAL  ANESTLIESIA 


Teeth. 
II.  Lower. 


13.  Second 
bicuspids. 


14.  First 
molars. 


15.  Second 
molars. 


16.  Third 
molars, 


Technique  of  injection  employed. 

'-' —  —    -  -    .     Mountings 

(b)  in  cases  complicated  of 

(a)  in  simple  cases.  by  periostitis,  parulis,    i       syringe, 

etc. 


Quantity  of  solution 

in  labial  in  palatal 
or  buccal  or  lingual 
injections,    injections. 


Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccally  at  second  bi- 
cuspid. 

Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccally  in  papilla  of 
first  molar. 

Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccally  in  papilla  of 
second  molar. 

Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccally  in  papilla  of 
third  molar. 


Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccally  in  papilla  of 
first  bicuspid. 

Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccally  in  papilla  of 
second  bicuspid. 

Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccally  in  papilla  of 
first  molar. 

Conductive  anesthesia 
from  mandibular  fora- 
men, and  injection 
buccally  in  papilla  of 
second  molar. 


(a)   and   (b)     (a)  1.5  c.c. 
Hub  C  and     (b)  2.5  c.c. 
needle  No. 
17  c. 

(a)    and  (b)     (a)  2.5  c.c. 
Hub  C  and     (b)  2.5  c.c. 
needle  No. 
17  c. 

(a)   and   (b)     (a)  2.5  c.c. 
Hub  C  and     (b)  2.5  c.c. 
needle  No. 
17c. 

(a)   and    (b)  '  (a)  2.5  c.c. 
Hub  C  and     (b)  2.5  c.c. 
needle  No. 
17  c. 


ADDITIONAL  EXPLANATION  OF  TABLES 

The  period  of  waiting  in  cases  Nos.  I  to  lO  is  about  ten  minutes; 
after  injection  in  the  inferior  dental  foramen,  as  in  Nos.  li  to  i6,  twenty 
minutes.  In  Nos.  13  to  16  no  injection  lingually  is  required.  All 
combinations  of  anesthesia  of  several  teeth  on  one  side  can  easily 
be  calculated  by  applying  to  the  first  and  the  last  tooth  of  the  series 
to  be  anesthetized  the  technique  specially  indicated  for  the  same  in 
the  tables.  If,  for  example,  the  right  half  of  the  upper  jaw  from  the 
canine  to  the  third  molar  is  to  be  anesthetized,  an  injection  is  made  in 
the  canine  fossa  at  the  root  apex  of  the  canine;  the  needle  is  then 
advanced  along  the  periosteum  to  the  root  apex  of  the  second  bicuspid, 
injecting  altogether  2  c.c.  Then  I  c.c.  is  injected  at  the  maxillary 
tuberosity,  about  10  drops  in  the  posterior  palatine  foramen,  and  about 
0.25  c.c.  palatally  between  the  canine  and  first  bicuspid. 

In  order  to  anesthetize  the  lower  teeth  from  the  lateral  incisor  to 
the  third   molar,  injections  are  made  in  the  inferior  dental   and   the 


COXCLL'SION  195 

mental  foramina,  also  in  the  mental  fossa  on  the  same  side,  and  lin- 
gually  behind  the  canine  in  order  to  paralyze  the  lingual  nerve,  employ- 
ing about  0.5  c.c.  of  the  solution.  If  necessary,  no  hesitation  need  be 
felt  about  injecting  in  the  inferior  dental  foramina  on  both  sides 
simultaneously.  Untoward  sequelae,  alarming  symptoms  of  paralysis 
or  tongue-biting  have  not  been  observed  so  far.  In  the  same  way  the 
entire  upper  jaw  can  be  anesthetized  by  injections  at  the  maxillary 
tuberosity,  and  in  the  infra-orbital  foramen  on  either  side.  For  major 
operations  especially,  conductive  anesthesia  is  most  favorably  indicated 
and  of  great  value,  in  fact  an  indispensable  substitute  for  general 
anesthesia  as  formerly  employed  in  such  cases. 

CONCLUSION 

In  closing  it  should  be  said  that  these  pages  are  intended  above  all 
to  stimulate  a  careful  study  of  the  practical  application  of  local  anes- 
thesia, and  for  this  reason  numerous  questions  of  a  theoretical  nature 
have  been  merely  grazed  on  the  surface  or  left  untouched.  This  policy 
seemed  specially  advisable  since  Braun  in  his  great  text-book  on  Local 
Anesthesia  has  entered  into  the  most  minute  details. 

May  these  pages  contribute  to  popularize  local  anesthesia  moi'e  and 
more,  so  as  to  render  it  the  common  property  of  all  dentists.  The 
numerous  recent  efforts  in  advocacy  of  general  anesthesia  in  dentistry 
are  in  all  probability  doomed  to  failure,  owing  to  the  far  greater  ad- 
vantages afforded  by  local  anesthesia  applied  b}'  skilled  hands.  The 
injection  method  of  local  anesthesia  is  equally  suitable  for  the  surgical 
as  for  the  conservative  practice  of  dentistry,  and,  despite  the  conten- 
tions to  the  contrary  that  have  been  raised,  is  to-day  most  favorably 
indicated  for  dentinal  anesthesia.  To  be  sure,  success  in  this  accessory 
field  cannot  be  obtained  by  superficial  study,  but  must  be  acquired  by 
painstaking  practice,  especially  in  the  technique  of  injection.  On  the 
other  hand,  by  obtaining  such  success  we  shall  be  not  only  enhancing 
the  confidence  of  our  patients,  but  materially  contributing  to  sub- 
stantiate the  great  importance  of  dentistry  as  a  science,  and  to  raise 
its  professional  standard  in  the  ej-es  of  the  whole  ci\ilized  world. 


INDEX 


Abscess,  acute,  in  maxilla,  supra-orbital  injec- 
tion for,  174 
alveolar,  anesthesia  in,  167 
Abscessed  upper  canine,  mucous  anesthesia  in, 

150 
Absorption  of  local  anesthetics,  36 
Accidents  after  novocain  injections.  80 
Acoin,  23,  36 
Adralgin,  47 
AdrenaUn,  24,  44 

Alveoli,  minute  distribution  of  nerves  in,  143 
sections  of,  117,  120,  121 
structure  of,  118 
Alveolar  ridges,  105 
Alypin,  23,  36 
Ampoules  for  novocain-thvmol  solution,  51,  54, 

66 
Amyl  nitrite  in  collapse,  74 
Analgesia,  definition  of,  21 
b)'  freezing  agents,  34 
Anamnesia,  29,  79 
Anastomoses,  stimuli  referred  by,  136 

of  trigeminal  nerve,  135 
Andolin,  47 

Anemia,  dosage  of  suprarenin  in,  46 
harmlessness  of  novocain  in,  95 
of  mucous  tissue  during  anesthesia,  157 
produced  by  suprarenin  solution,  44 
Aneson,  36 

Anesthesia,  definition  of,  21,  25 
of  mucous  membrane,  149 
of  periosteum,  150 
in  therapy  of  inflammation,  97 
Anesthesin,  23,  36 

Ankylosis,  novocain  contraindicated  in,  95 
Anterior  teeth,  duration  of  anesthesia  by  way  of 
infra-orbital  foramen  in,  190 
injection  for,  163 

lower,    injection    in    mental    fossa    for 
anesthesia  of,  164 
mucous  anesthesia  in,  164 
upper,  nerve  supply  of,  142 
points  of  injection  for,  151 
Antidotes  in  collapse,  73 

Arteriosclerosis,  harmlessness  of  novocain  in,  79, 
95 


Arteriosclerosis,  suprarenin  in,  46 
Artery,  inferior  dental,  184 
internal  carotid,  132 


B 


Bernatzik's  solution,  47 
Bicuspids,  lower,  bony  sockets  of,  124 
nerve  supply  of,  143 
second,  injection  for,  162 

of  buccal  nerve  for  anesthesia 
of,  186 
upper,  bony  sockets  of,  108,  no,  123 
duration  of  anesthesia  in.  189 
mucous  anesthesia  in,  155 
nerve  supply  of,  139 

first,  position  of  needle  for  mucous 
anesthesia,  156 
region,  injection  in,  158 
Bloodvessels,  nerve  supply  of,  148 
Boennighausen's  local  anesthetic  "corona,"  47 
Bromural  in  prophylactic  treatment  of  ner\-ous 

patients,  102 
Bruises,  anesthesia  in  treatment  of,  98 


Canal,  anterior  palatine,  12S,  135 
inferior  dental,  130,  134 
infra-orbital,  128 

mandibular,  in,  119,  130,  134,  143 
pterygopalatine,  128 
Cancellous  portions  of  maxillce,  103 
Canines,  lower,  anesthesia  bj'  injection  in  mental 
fossa,  165 
bony  sockets  of,  124 
position  of  needle  for  injection  in.  163 
upper,  abscessed,  mucous  anesthesia  in.  150 
bony  sockets  of,  108,  123 
duration  of  anesthesia  in,  1S9 
infra-orbital    injection    for    conductive 

anesthesia  of,  174 
mucous  anesthesia  in,  156 
nerve  supply  of.  139 
position  of  needle  for  injection  in,  155 
Capillaries,  nerve  supply  of,  14S 


198 


INDEX 


Cavity  preparation,  87 
Chemical  action  of  local  anesthetics,  35 
Children,  dosage  of  novocain  solution  in,  57 
Chloral  hydrate  for  nervous  patients,  88 
Chlorosis,  harmlessness  of  novocain  in,  95 
Cocain,  action  of,  39 

acute  intoxication  from,  37 

and  adrenalin,  toxicity  of,  38 

contraindications  to,  39 

deaths  from,  38 

intoxication  and  hysteria,  33 

KoUer's  demonstration  of,  22 

maximal  dose  of,  37 

non-toxic  solutions  of,  38 

psychic  disturbances  from,  38 

substitutes  for,  23,  36,  39 

toxic  action  of,  83 

toxicity  of,  23,  37 
Collapse,  antidotes  in,  73 
Conductive  anesthesia,  definition  of,  25 
Halstedt's  method,  22 
in  mandible,  176 
in  maxilla,  171 
principles  of,  188 
technique  of,  169 
Contraindications  to  novocain,  95 
Cortical  mass  in  maxillary  bones,  103 
Coryza,  anesthesia  in  treatment  of,  98 
Cranial  operations,  local  anesthesia  in,  58 
Crown  and  bridge  work,  95 


D 

Dangers  of  local  anesthesia,  71 
Deciduous  teeth,  putrescent,  ether  spray  in,  168 
Deglutition,  difficult,  following  mandibular  injec- 
tion, 186 
Dentin,  anesthesia  of,  85 

sensibility  of,  145 
Devitalizing  paste,  77 

Diabetics,  harmlessness  of  novocain  in,  79,  95 
Diffusion  of  anesthetics,  details  of,  125 
Dioscorides'  experiment  with  local  anesthesia,  21 
Disinfection  of  field  of  operation,  69 
Dolantin,  48 
Dolorant,  48 
Duration  of  local  anesthesia  obtained,  189 


E 

Ears,  dental  pain  referred  to,  136 
Edema  due  to  lack  of  sterility,  70 
Electric  currents,  tests  of  extent  of  local  anes- 
thesia by,  190 

tests  of  nerve  supply  b3^  136 
Eroticism,  32 
Ether  spray,  71,  168 

Richardson's  experiments,  22 
Ethyl  chlorid  spray,  34,  71,  168 


Eucain  alpha  and  beta,  23.  36 

Eusemin,  39 

Eyes,  relations  between  teeth  and,  136 


Failures,  sources  of,  56 
Fissure,  sphenoidal,  137 
Foramen,  anterior  palatine,  no,  142,  161 
apical,  147 
incisive,  no 
inferior  dental  ,111 

variations  at  different  ages,  114 
infra-orbital,  109,  130,  174 

extent  of  anesthesia  by  way  of,  190 
mandibular,  III,  176 
mental,  109,  119,  130,  134 

injection  in,  187 
oblique,  in 
ovale,  130 
posterior  palatine,  no 

duration  of  anesthesia  by  way  of, 

189 
injection  for  mucous  anesthesia  in 
upper  molars,  158 
rotundum,  128 
spinosum,  130 
Foramina  in  anterior  surface  of  maxillae,  108 

in  palatal  surface  of  maxillas,  no 
Fossa,  anterior  palatine,  injection  contraindicated 
in,  161 
incisive,  105 
mental,  106,  164 

injection  in,  164,  187 
retromolar,  in,  178 
sphenomaxillary,  128 
Fracture  of  skull,  local  anesthesia  in,  58 
Freezing  agents,  34 

G 

Ganglion,  ciliary,  126 

Gasserian,  126 

Meckel's,  128 

otic,  132 

semilunar,  126 

sphenopalatine,  128 
General  anesthesia,  dangers  of,  25 

anesthetics,  96 
Gingiv3S,  spongy,  157 

Gingival  papillas  in  mandible,  injection  in,'l64 
Glands,  mandibular,  132 

parotid,  136 
Gum  boils,  ethyl  chlorid  in  incisions  in,  168 


Hallucinations,  sexual,  27,  32 
Healing  process,  modification  by  anesthesia, 
loi 


INDEX 


]!)!) 


Heart  disease,  harmlessness  of  novocain  in,  95 
Hemolysis,  local  anesthetics  producing,  47 
Hemorrhage,  arrest  of,  77 
Holocain,  23,  36 
Hubs  for  injection  syringe,  64 
Hypalgesia,  etiology  of,  20 
Hyperalgesia,  etiology  of,  20 
Hypertonic  solutions,  effects  of,  47 
Hypodermic  needles,  63,  65 
breaking  of,  72 
manipulation  of,  151 

in  infra-orbital  injection,  174 
in  injection  in  mandibular  foramen, 
176,  178,  181 
at  maxillary  tuberosity,  172 
in  mental  fossa,  165,  187 
at  posterior  palatine  foramen, 

158 
of  swollen  areas,  168 
in  lingual  injection  in  mandible,  166 
in  mandibular  anesthesia,  118 
in     mucous    anesthesia     in     lower 

molars,  167 
in    palatal    injection    for    mucous 
anesthesia,  157 
treatment  of,  65 
Hypotonic  solutions,  effects  of,  47 
Hysteria,  73,  96 

attacks  after  novocain,  84 
cocain  intoxication  and,  33 
Hysterics,  anesthesia  in,  99 


Idiosyncrasies,  39,  72 
Incisor  region,  injection  in,  157 
Incisors,  lower,  anesthesia  by  injection  in  mental 
fossa,  165 
bony  sockets  of,  124 
nerve  supply  of,  143 
upper,  bony  sockets  of,  123 

central,  bony  sockets  of,  105 

position  of  needle  for  injection  in, 
159 
duration  of  mucous  anesthesia  in,  189 
infra-orbital    injection    for    conductive 

anesthesia  of,  174 
mucous  anesthesia  in,  156 
nerve  supply  of,  139 
Indications  for  local  anesthesia,  85 
Infection,  postoperative,  prophylaxis  for,  75 
Infiltration  anesthesia,  22 

Schleich's,  disadvantages  of,  60 
Inflammation,  anesthesia  in  therapy  of,  97 

therapeutic  measures  in,  76 
Inflammatory  swelling,  anesthesia  in,  167 
Infra-orbital  injection,  174 

Injection  anesthesia,  diagram   illustrating  tech- 
nique and  dosage  for,  183 
instrumentarium  for,  61 


Injection  anesthesia  in  mandible,  164 

in  maxilla,  buccal  and  labial,  for  mucous 
anesthesia,  154 
palatal,  for  mucous  anesthesia,  157 
in  mucous  membrane,  technique  of,  151 
of  several  teeth,  technique  of,  194 
at  superior  maxillary  tuberosity,  140 
tables  for,  191 
technique  of,  149 

Insanity,  anesthesia  in,  98 

Instrumentarium,  61 

lodin,  for  disinfecting  field  of  operation,  69 

Irritation,  combating  local,  100 
effects  of,  20 

Isotonia,  of  injecting  solutions,  47 


Kidney  disease,  harmlessness  of  novocain  in,  79 
Koller's  demonstration  of  cocain,  22 
Krause's  world  anesthetic,  47 


Lacerations,  anesthesia  in  treatment  of,  98 
Legal  questions,  28 

Lethal  doses  of  cocain  and  novocain,  compara- 
tive, 41 
Lingula,  mandibular,  112,  180 
Local  anesthesia,  advantages  over  general,  25,  59 

agents  for,  34 

dangers  of,  71 

indications  for,  26,  85 

in  surgery,  58 

versus  general,  24 
anesthetics,  advantages  of,  in  surgery,  60 

diffusion  of,  125 

producing  hemolysis,  47 

requirements,  48 
Loose  roots  and  teeth,  mucous  anesthesia  in,  164 


M 


Mandible,  ascending  ramus,  iii,  176 
body  of,  176 
inner  surface  of,  no 
lingual  injection  in,  165 
nerve  supply  of,  143 

of  superficial  areas,  140 
Mandibular  anesthesia,  difficulties  in,  1 8 
duration  of,  190 
insertion  of  needle  in,  113 
foramen,  injection  in,  176 
injection,  effect  of,  186 
technique  of,  176 
Maxilla,  nerve  supply  of,  127 

of  palatal  surface  of,  142 
of  superficial  areas  of,  139 


200 


INDEX 


Maxilla,  palatal  surface  of,  109 
MaxillsB,  areas  of  nerve  supply  of,  137 
in  old  persons,  106 
surfaces  of,  103 
anterior,  104 
posterior,  109 
in  young  persons,  107 
Maxillary  bones,  anatomy  of,  103 

tuberosity,  injection  at,  171 
Medullary  anesthesia,  23 
Mental  injection,  187 
Minors,  legal  question  of  treating,  27 
Molars,  lower,  bony  sockets  of,  124 

first    and    second,    injection    of    buccal 

nerve  for  iinesthesia  of,  186 
lingual  injection  in,  167 
mucous  anesthesia  in,  167 
nerve  supply  of,  143 
position  of  needle  for  injection  in,  162 
upper,  bony  sockets  of,  108,  no,  123 

conductive   anesthesia   by  injection   at 

maxillary  tuberosity,  171 
duration  of  anesthesia  in,  189 
first,  position  of  needle  for  injection  in, 

172 
injection  at  posterior  palatine  foramen 

for  anesthesia  of,  158 
mucous  anesthesia  in,  155 
nerve  supply  of,  139 
Moore,  James,  experiments  with  compressing  and 

severing  nerve  trunks,  22 
Morphin,  local  application  of,  loi 

for  nervous  patients,  89 
Mucous  anesthesia,  definition  of,  25 
duration  of,  189 
in  mandible,  164 

method  of  palatal  injection,  157 
in  maxilla,  149 

method  of  buccal  and  labial  injec- 
tion, 157 
period  of  waiting,  169 
principles  of,  169 
membrane,  behavior  during  anesthesia,  156 
,  disinfection  of,  69 
Muscles,  external  rectus,  137 

origins   and   insertions   upon   inner   surface 

of  mandible,  179 
tensor  palati,  128,  136 
tympani,  134,  136 
Mylohyoid  groove,  112 


N 


Nalicin,  47 

Narcotic  slumber  after  novocain,  80 

Nasal  spine,  anterior,  105,  175 

Needles  for  injection.     See  Hypodermic  needles. 

Nephritis,  harmlessness  of  novocain  in,  79,  95 

Nerve  anastomoses,  135 

stimuli  referred  by,  136 


Nerve  distribution,  minute,  in   alveolar   process 
and  pulp,  143 
filaments  in  pulp,  structure  of,  147 
plexus,  glossopharyngeal,  132 

sympathetic,  132 

trigeminal,  135 

tympanic,  132 
Nerves,  abducent  oculomotor,  126 
auriculotemporal,  130,  136 
buccal,  paralyzation  of,  i85 
buccinator,  130,  140,  143 
caroticotympanic,  132 
chorda  tympani,  132 
ciliary,  128 
facial,  132 
frontal,  126,  137 
glossopharyngeal,  132 
inferior  dental,  130,  134,  135,  140,  143 

anesthesia  of,  176 
infra-orbital,  128,  130,  135 
infratrochlear,  128 
lacrymal,  126,  137 
lingual,  130,  132,  134,  143 

anesthetization  of,  179,  184 

distribution  of,  131 
mandibular,  126,  130,  134 
masseteric,  130 
maxillary,  126,  128 
mental,  130,  134,  143 
mylohyoid,  130,  134,  143 
nasal,  126,  137 

nasopalatine,  128,  135,  142,  161 
oculomotor,  126,  137 
ophthalmic,  126 
optic,  126,  137 
of  orbit  and  maxilla,  127 
orbital,  128 
palatine,  128,  136 

anterior,  135,  142 

distribution  of,  131 
parotid,  136 

petrosal,  small  superficial,  132 
pterygoid,  130 

interna],  134 
sensory,  functions  of,  19 
spheno-ethmoidal,  128 
sphenopalatine,  128 
suborbital,  140 
superior  dental,  128,  139 
anterior,  174 
distribution  of,  133 
posterior,  172 

maxillary,  172 

anesthetization  of,  59 
distribution  of,  132 
supra-orbital,  126 
supratrochlear,  126 
temporal,  deep,  130 
temporomalar,  128 
trigeminal,  125 

branches  of  supply,  134 


INDEX 


201 


Nerves,    trigeminal,    communications     between 
divisions   of,    136 
distribution  of,  129 
Vidian,  128 
Nerve   supply   of    bloodvessels   and    capillaries, 
148 
of  maxilte,  125 
areas  of,  137 
Nervous  patients,  73 

chloral  hydrate  for,  88 
morphin  for,  89 
prophylactic  treatment  of,  102 
quinin  for,  88 
system,  central,  action  of  novocain  on,  82 
Nervus  intermedius,  132 
Neurasthenics,  local  anesthesia  in,  96 
Neuritis  of  optic  nerve,  dental  origin  of,  137 
Neurofibrillas,  148 
Nirvanin,  23,  36 

Non-isotonic  local  anesthetics,  47 
Novocain  accidents  after  injection,  80 
action  of,  48 

on  central  nervous  system,  82 
advantages  of,  41 
case  of  toxic  action  of,  81 
contraindications  to,  95 
dosage  in  children,  57 

in  weakly  patients,  57 
general  effects  after  absorption,  41 
hysterical  attacks  after,  84 
local  action  of,  72 
maximal  dose,  42 
normal  solution,  52,  55,  56 
physiological  salt  solution  for  dissolving,  54 
solutions,  40 

in  ampoules,  four  strengths,  52 
bottles  for,  56 

for  extended  surgical  operations,  53 
preparation  of,  55,  66 
stability  of,  55 
sterilization  of,  55 
in  surgery,  57 
tablets,  53 
tamponade  with,  76 
temperature  of,  51 
untoward  effect  of  soda  on,  54 
-suprarenin,  43 

solution,  excretion  of,  48 
-thymol  solution  in  ampoules,  manipulation 
of,  51 


O 


Oblique  line,  external,  iii,  177 
internal,  iii,  177,  180 
Odontoblastic  layer,  143 
Odontoblasts,  145 
Operator's  duties,  29 
Orbit,  126 

nerves  of,  127 


Orthoform,  23,  36 
Orthonal,  48 
Osmosis,  47 


Pacini's  corpuscles,  143 
Pain,  physiology  of,  19 

postoperative.    See  Postoperative  pain. 

psychology  of,  17 

referred,  136 
Palate,  nerve  supply  of,  142 
Papilla,  incisive,  injection  in,  175 
Parulis,  anesthesia  in,  167 
Pericementum,  143 
Perinephrin,  47 
Perineural  anesthesia,  22 
Perineurium,  147 
Periosteal  anesthesia,  150 
Periosteum  of  alveolar  process,  143 

of  maxillEe,  150 
Periostitis,    severe    purulent,    novocain    contra- 
indicated  in,  95 
Phlegmon,  novocain  contraindicated  in,  95 
Pipette,  standard,  45 
Pohl's  a-c  subcutaneous  tablets,  47 
Postoperative  pain,  74 

prevention  of,  loi 
therapeutic  measures  in,  75 
Pregnancy,  harmlessness  of  novocain  in,  95 
Preliminary  measures,  29 
Pressure  anesthesia,  35 

for  pulp  extirpation,  90 
Process,  alveolar,  minute  distribution  of  nerves 
in,  143 
structure  of,  116 

coronoid,  1 1 1 

septal,  118 
Prophylactic  treatment  of  timid  patients,  102 
Pulmonary  disorders,  harmlessness  of  novocain 

in.  95 
Pulp  amputation,  91 

anesthesia  of,  85 

debris,  removal  of,  94 

extirpation,  pressure  anesthesia  for,  go 

hypertrophy,  treatment  of,  91 

minute  distribution  of  nerves  in,  143 

preservation  of,  partial,  92 

stones,  94 

structure  of  nerve  filaments  in,  147 
Pulpitis,  86,  94 
Pulse,  watching  the,  31 

Putrescent  conditions,  severe,  ethyl  chlorid  in, 
168 

deciduous  teeth,  ether  spray  in,  168 


Quinin  for  nervous  patients, 


2Cf2 


INDEX 


R 


Ramus,  ascending  of  mandible,  176 

Records,  keeping  accurate,  of  cases,  31 

Regional  anesthesia,  22 

Renoform,  24 

Resection  of  maxilla,  infra-orbital  iniection  for, 

local  anesthesia  in,  59 
Respiration,  watching  the,  31 
Responsibilities,  operator's,  31,  77 
Richardson's  ether  spray,  22 
Ritsert's  simplex  subcutin,  48 
Root  canal  treatment,  94 

under  local  anesthesia,  86 


Schroder's  analgeticum,  48 
Scopolamin-morphin  in  prophylactic  treatment  of 

nervous  patients,  102 
Sedatives  before  injection,  88 

effect  of,  1 01 
Septa,  alveolar,  118 
Sexual  affections,  32 

hallucinations,  27,  32 
Shock,  73 
Sinus,  maxillary,  142 

operations,  local  anesthesia  in,  58 
Soda,  untoward  effects  on  novocain,  54 
Solubility  of  local  anesthetics,  36 
Spongiose  mass  in  maxillary  bones,  103 
Spongy  gums,  157 
Stasis  bandage,  68 
Sterility  of  injecting  solutions,  49,  5^ 

of  novocain  tablets,  53 
Sterilization  of  field  of  operation,  69 

of  injecting  solution,  55,  66 

of  instruments,  66 
Stovain,  23,  36 
Subcain,  47 
Subcutin,  23 

Suggestion,  mental,  in  local  anesthesia,  27 
Suprarenin,  dosage  of,  43,  46 

effects  of,  23,  43,  46 

stability  of,  44 

toxicity  of,  45 
Surgery,  local  anesthesia  in,  58 
Swelling,  inflammatory,  anesthesia  in,  167 
Syncope,  73 
Syringe,  hubs  for,  64 

for  injection,  62 

manipulation  of,  151 

in  anesthesia  of  swollen  areas,  168 

in  buccal  and  labial  injection  for  mucous 

anesthesia,  152 
in  infra-orbital  injection,  174 
in  injection  in  mandibular  fcramen,  176, 
178,  181 
in  mental  fossa,  165 


Syringe,  manipulation  of,  in  injection  at  maxillary 
tuberosity,  172 
-  at  posterior  palatine  foramen.  160 
in  lingual  injection  in  mandible,  166 
in  meiital  injection,  187 
in  mucous  anesthesia  in  lower  molars, 
167 
needles  for,  63,  65 

position  in  mandibular  anesthesia,  iiS 
treatment  of,  66 


Tablets  of  novocain,  53 
Telodendrions,  148 
Temperature  of  novocain  solution,  51 
Third  person,  legal  question  of,  78 

presence  of  advised,  27,  32 
Thymol,  as  admixture  to  injecting  solution,  48.  50 
anesthesia  by,  49 
antiseptic  property  of,  49,  51 
reduction  of  body  temperature  by,  50 
Thyroidectomy,  local  anesthesia  for,  26 
Tomes'  fibrils,  145 

Tongue,  anesthesia  in  treatment  of  injuries  of,  98 
duration  of  anesthesia  in  mandibular  injec- 
tion, 191 
operations,  local  anesthesia  in,  60 
Toxic  action  of  cocain,  83 

of  novocain,  case  of,  81 
Toxicity  of  local  anesthetics,  36 
Triangle,  retromolar,  1 1 1 
Tropococain,  23,  36 
Tubercles,  internal  genial,  no 
Tuberosity,  maxillary,  130 

duratiorl  of  anesthesia  induced  at,  189 
injection  at,  140 
Tunica  adventitia,  148 
media,  148 

U 
Udrenin,  47 

V 

Validol  in  collapse,  74 

Vascular  walls,  nerve  supply  of,  148 

Vater's  corpuscles,  143 

W 

Waiting  periods  after  injections,  189,  194 

Weakly  patients,  novocain  dosage  in,  57 

Wilson's  anesthetic,  47 

Winter's  anesthetique  local,  47 

Witnesses,  presence  of,  imperative.     See  Third 

person. 
Witte's  local  anesthetic,  48 
Wounds,  anesthesia  in  treatment]^of,  97 
treatment  of,  75 


YOHIMBIN,  36 


&/?!/  J  > 


^w 


RK501 


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-   COLUMBIA  UNIVERSITY  LIBRARIES  His.slx, 
Local  anesthesia  in  dentistry-.. 


2002448882 


